Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure in response to an allegation of resident-to-resident sexual abuse. Two certified nursing assistants witnessed one resident placing their hand up another resident's shorts and touching the resident's vagina on two occasions. Despite this, the administrator in training confirmed that no investigation was conducted, and no report was submitted to the state agency. The electronic medical records for both residents did not include any interventions or increased supervision to protect the affected resident or others from further abuse. Additionally, the alleged perpetrator continued to have unsupervised access to all residents in the facility following the incident. Staff interviews revealed that the administrator was made aware of the allegations but did not provide any immediate safety interventions and delayed the start of the investigation. Observations showed the alleged perpetrator moving freely throughout the facility and in proximity to the victim after the incident. The facility's abuse policy requires immediate reporting, thorough investigation, protective measures, and timely submission of a final report to the state agency, none of which were followed in this case.