Failure to Investigate Sexual Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, resulting in a deficiency cited at Immediate Jeopardy level. The incident involved a female resident with severe cognitive impairment, behavioral disturbances, and a history of aggression and wandering, and a male resident with moderate cognitive impairment and no prior behavioral issues. On the day of the incident, staff observed escalating inappropriate interactions between the two residents, including physical contact and attempts to sit together, but did not maintain adequate supervision. Eventually, both residents were found in the male resident's room, with the female resident lying on the bed with her pants unbuttoned and the male resident standing beside her with his hand inside her pants. Both LPNs present at the scene confirmed witnessing this event. The facility's investigation into the incident was incomplete and inconsistent. The Administrator initially failed to obtain statements from all involved staff, provided conflicting information about witness identities, and did not interview the male resident involved. There were discrepancies in the documentation and staff schedules, and the Administrator relied on statements that were later found to be inaccurate or attributed to the wrong individuals. The investigation was not promptly or thoroughly conducted, as required by the facility's own abuse policy, and the Administrator only substantiated the abuse allegation after being confronted with new information from staff interviews days after the incident. Additionally, the facility did not implement or document appropriate supervision or care plan interventions for either resident immediately following the incident. Orders for increased monitoring were either discontinued or not implemented, and care plans were not updated in a timely manner to address the behavioral risks. The lack of a prompt, thorough investigation and failure to ensure resident safety and supervision contributed to the deficiency cited by surveyors.