Failure to Investigate Sexual Abuse Allegation per Policy
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of sexual abuse for one resident. The facility's policy requires immediate notification of the Nursing Home Administrator (NHA) or Director of Nursing (DON), reporting to the state health department, contacting the County Area Agency on Aging, and conducting an internal investigation for all abuse allegations. However, documentation and interviews revealed that a specific allegation of sexual abuse was not fully investigated as required by policy. A resident with diagnoses of heart failure, anxiety, and depression reported being handled roughly by a nurse aide during incontinence care, describing the experience as extremely painful and humiliating. The resident stated that the incident felt like sexual abuse and expressed ongoing emotional distress. The event was initially reported as physical abuse, and the involved staff member was suspended pending investigation. The resident was assessed for physical injury, and law enforcement was contacted. However, the specific allegation of sexual abuse, as documented in a behavior note by an LPN, was not communicated to the DON and was not included in the facility's investigation. Interviews with staff confirmed that the LPN who documented the resident's statement about sexual abuse did not recall reporting it to anyone, and the DON stated she was unaware of the sexual abuse allegation. As a result, the facility did not conduct a complete and thorough investigation into the sexual abuse allegation, failing to follow its own policies and procedures for abuse prevention and investigation.