Failure to Investigate and Report Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to provide evidence that alleged violations involving sexual abuse among five residents were thoroughly investigated. Multiple clinical record reviews, staff interviews, and policy reviews revealed that incidents of inappropriate sexual and physical behaviors by one resident towards several female residents were either not documented, not reported to appropriate supervisory staff, or not investigated according to facility policy. Staff interviews indicated that several incidents, such as inappropriate touching, attempts to take female residents to the perpetrator's room, and physical aggression, were observed by various staff members, including CNAs, housekeepers, and LPNs. However, these incidents were not consistently reported to the Director of Nursing (DON) or the Abuse Coordinator, and in some cases, staff made unilateral decisions not to escalate the reports, believing the incidents did not warrant further action if no physical harm was observed. Clinical documentation showed repeated behavioral issues, including sexualized behaviors and aggression, by a resident with moderate cognitive impairment and a history of psychiatric diagnoses. Despite multiple behavioral notes and staff observations of inappropriate contact with other residents—many of whom had severe cognitive impairment and were unable to protect themselves—there was a lack of thorough investigation or documentation of these incidents in the affected residents' records. Interviews with staff revealed a lack of clarity and consistency in reporting procedures, with some staff assuming others had reported incidents or believing that redirection was sufficient if no injury occurred. The DON and Abuse Coordinator were not made aware of several incidents, and the facility's policy requiring immediate reporting and investigation of abuse allegations was not followed. Additionally, the review of facility records and interviews highlighted that the required notifications to state agencies and thorough investigations were not completed for several incidents. The facility's own policy mandates immediate reporting of all abuse allegations to supervisory staff and external agencies, but this was not adhered to. The lack of documentation and investigation could result in further incidents not being addressed, and the facility did not have evidence that it responded appropriately to all alleged violations as required.