Failure to Interview Key Staff in Sexual Abuse Allegation Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving a resident with intact cognition and a diagnosis of acute chronic diastolic heart failure. The allegation, reported by a hospital case manager, stated that a male staff member inserted his thumb into the resident's rectum multiple times while a female staff member spanked the male staff member. The resident could not specify the exact date and time of the incident but indicated it occurred late at night. The facility's abuse prevention policy required an investigation to be initiated for any findings of potential abuse or neglect, including determining cause and effect and protecting the alleged victim during the investigation. Despite identifying a male CNA who worked the relevant shifts, the facility's investigation file contained no evidence that any male staff were interviewed. The Executive Director acknowledged that although a male staff member was identified, there was no documentation of attempts to contact him, nor was this information included in the investigation report. The identified CNA confirmed he was not contacted or informed about the investigation. The Director of Nursing Services stated that she would have expected any involved male staff to be interviewed or contacted as part of the investigation.