Failure to Thoroughly Investigate Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate three separate allegations of sexual misconduct involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, Alzheimer's disease, and major depressive disorder. The resident, who is dependent for daily activities and has an activated Health Care Power of Attorney, reported incidents of sexual abuse on three occasions. Despite the facility's policy requiring prompt and comprehensive investigations, the investigations conducted did not include all necessary interviews or relevant questions specific to the allegations. In each case, the facility interviewed a standard sample of five residents using generic questions about rough treatment, feeling rushed, or staff frustration, none of which directly addressed the nature of the sexual abuse allegations. The resident's roommate, who could have been a key witness, was not interviewed for two of the incidents. Additionally, in one incident where a male staff member was present during the alleged event, no statement was obtained from him. The facility also failed to document whether any men were in the building at the time of one of the reported incidents. Interviews with facility leadership revealed that the investigation process was based on sampling rather than targeting individuals directly involved or potentially knowledgeable about the incidents. The Director of Social Services and the Nursing Home Administrator confirmed that their process did not require interviewing roommates or all relevant staff, and that the same set of unrelated questions was used for all resident interviews. This approach resulted in incomplete investigations that did not meet the facility's own policy requirements for abuse allegations.