Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse involving two residents. Documentation shows that one resident, who had a history of inappropriate sexual behaviors and severe cognitive impairment, was reported by another resident to have received oral sex. Both residents involved denied any sexual contact when interviewed. Despite these denials, there were multiple documented incidents of sexually inappropriate behaviors, including attempts to enter female residents' rooms, physical contact such as rubbing another resident's legs, and being observed in intimate situations with another resident. The records indicate that staff were aware of ongoing sexually inappropriate behaviors between the two residents, as evidenced by repeated documentation of incidents and the implementation of 15-minute checks and behavior contracts. Both residents had complex medical and psychiatric histories, including cognitive impairment, bipolar disorder, and a history of sexually inappropriate behaviors. The facility's own policy required a thorough investigation of all alleged violations, including interviewing all involved parties and witnesses, but the report confirms that no such investigation was completed regarding the sexual abuse allegation between the two residents. Interviews with facility leadership, including the DON and Administrator, verified that an investigation into the alleged sexual abuse was not conducted. The facility policy mandates that an investigation be completed within five working days of notification, but this protocol was not followed. The lack of a thorough investigation into the allegation constitutes the deficiency cited in the report.