Failure to Thoroughly Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse made by a resident with moderate cognitive impairment, who reported that a male CNA exposed himself and forced her to touch his genitals. The resident described the alleged perpetrator in detail, and documentation showed that the CNA had provided her with showers, although records were inconsistent due to the CNA documenting under another staff member's name. The initial investigation by facility staff was limited, with only a single interview of the resident and a review of documentation that did not accurately reflect who had provided care, due to improper documentation practices. The Director of Staff Development (DSD) and Director of Nursing (DON) did not follow the facility's abuse investigation protocol, as required by policy. The DSD did not interview all relevant staff or residents, failed to document staff interviews, and did not include the resident's roommate or other potentially involved individuals in the investigation. The DSD also admitted to not being trained in abuse investigations and concluded the investigation quickly due to perceived inconsistencies in the resident's account. The DON did not assist in the investigation or ensure that it was thorough, and the Administrator did not provide formal training on proper investigative procedures. Additional interviews revealed that another resident reported inappropriate touching by the same CNA, which was disclosed to the Administrator but not acted upon or reported according to policy. The facility's failure to conduct a comprehensive investigation, including interviewing all relevant parties and properly documenting findings, decreased the potential to protect the affected resident and others from harm. The facility's own policy required a thorough investigation, including interviews with all involved staff and residents, but this was not followed.