Failure to Conduct Thorough Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving one resident. The resident was admitted to the facility, later went to the emergency room, and upon return, a review of their clinical record showed a progress note indicating the resident woke up confused and believed there was a man in their room. The facility's investigation file revealed that the only interviews conducted were with the resident's responsible party and two male staff members from the unit. No interviews were conducted with other staff, such as the assigned nurse, nurse aide, other staff present at the time of the allegation, the nurse who documented the resident's report, or any other residents. The Administrator/Abuse Coordinator confirmed that no additional staff or residents were interviewed and was unaware of the earlier report made by the resident about a man in their room. The facility's policy required a careful and deliberate investigation, including gathering statements from the alleged victim and witnesses, and ensuring all relevant information was reported and recorded. The investigation did not meet these requirements, as key staff and potential witnesses were not interviewed, and relevant information was not fully gathered.
Plan Of Correction
Element I: Resident #304 continues to reside in the facility and states that she feels safe. She was physically assessed by the charge nurse and provider. Resident #304 is followed by the facility social worker with no effect to mood or routine noted. The allegation of abuse was investigated and not verified. All residents have the potential to be affected by this citation. Element II: An initial “care concern” audit was completed to ensure that there were not any existing or new allegations of abuse. There was nothing remarkable to report. Element III: The Senior Administrator educated the facility administrator on the facility policy titled, “Nursing Administration...Subject: Abuse and Neglect.” The Senior Administrator also provided education on the contents of a proper investigation, including, but not limited to, reviewing PCC documentation. The facility educated its staff on abuse reporting. Element IV: The Senior Administrator will perform weekly audits on any investigative files should the need arise, to ensure that necessary contents are provided. The findings from those audits will be reviewed by the administrator and submitted to the QAPI committee for review and recommendation. Element V: The Administrator is responsible for achieving and maintaining compliance with