Failure to Investigate and Remove Staff Following Sexual Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident with diagnoses including malignant neoplasm of the head, face, and neck, congestive heart failure, and post-traumatic stress disorder. The resident, who was cognitively intact and dependent on staff for personal hygiene and transfers, reported that a nurse aide had exposed her breasts and behaved inappropriately. The resident informed another nurse aide, who reported the incident to a registered nurse and the Administrator. Despite this, the Administrator dismissed the allegation as a hallucination and did not initiate an investigation. The nurse aide accused of abuse continued to work in the facility and was only removed from the resident's care assignment, not from the facility schedule. Multiple staff interviews confirmed that the allegation was reported up the chain of command, but neither the Director of Nursing Services nor the State Agency was notified at the time. The facility's abuse reporting policy required immediate notification of the Administrator, a thorough investigation, and removal of the alleged perpetrator from resident contact pending investigation. These steps were not followed, as the staff member remained on the schedule and the incident was not investigated until prompted by surveyor inquiry. The failure to act according to policy resulted in a lack of protection for the resident and a delay in addressing the abuse allegation.