Failure to Investigate and Respond to Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a male resident with vascular dementia, hemiplegia, and moderate cognitive impairment. The resident reported that a CNA had inappropriately touched him during a shower, but the incident was not immediately or properly reported, documented, or investigated according to facility policy. Multiple staff members became aware of the allegation at different times, but there was confusion and lack of clarity regarding who was responsible for reporting the incident to administration, resulting in delays and incomplete communication. Despite the resident expressing discomfort and specifically requesting that the alleged perpetrator not provide care, the CNA continued to work in the facility and had access to other residents. There was no evidence that the alleged perpetrator was removed from resident care or suspended pending investigation until much later. Documentation in the resident's progress notes, 24-hour reports, and other records did not reflect the allegation or any investigation, and the administrator denied knowledge of the incident until it was brought to her attention by surveyors. Interviews with staff revealed inconsistent understanding and execution of abuse reporting protocols. Some staff assumed others had reported the incident, while others failed to document or escalate the allegation as required. The facility's own abuse/neglect policy required immediate investigation and administrative review, but these steps were not followed. The lack of timely and comprehensive response to the allegation resulted in a failure to protect the resident and prevent potential further abuse or mistreatment.