Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough and complete investigation into an alleged incident of sexual abuse involving a resident and a nurse aide. The incident was reported by another nurse aide who witnessed inappropriate sexual conduct between the resident and the implicated staff member. The resident, who was cognitively intact, later confirmed the occurrence of the incident and previous similar interactions with the staff member. Despite these serious allegations, the facility's investigation was incomplete as it did not include interviews or statements from all staff members present during the incident. The resident involved in the incident was admitted to the facility with chronic obstructive pulmonary disease, type 2 diabetes, and muscle wasting. A recent assessment indicated that the resident was cognitively intact, with a BIMs score of 15. The incident was reported when a nurse aide observed the staff member engaging in inappropriate conduct with the resident. The resident later confirmed the incident and previous similar interactions with the staff member, indicating a pattern of inappropriate behavior. The facility's investigation was found lacking as it did not include interviews with all potential witnesses or involved staff members, such as the LPN and RN Supervisor who were present on the unit during the incident. This omission left gaps in the investigation, failing to provide a complete account of the events and staff awareness of the interactions between the resident and the implicated staff member. The facility's failure to conduct a thorough investigation was confirmed by the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Investigation completed. 2. The NHA or designee will review abuse investigations within the last 30 days to validate abuse investigations are completed timely. 3. The Regional Director of Operations will educate the NHA on timely completion of investigations, investigation process, preservation of evidence. The NHA will educate the IDT on the timely and accurate completion of abuse investigations. 4. The NHA or designee will audit abuse investigations weekly for 12 weeks to ensure investigations are completed timely and report findings to the QAPI committee.