Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to conduct a complete investigation into an allegation of sexual abuse involving a resident with mild cognitive impairment who reported being touched inappropriately by another resident. The resident, who was alert and oriented, stated that the incident occurred a few weeks prior and was reported to a nurse, but she could not recall specific details or witnesses. Documentation showed that the resident had a history of making accusations, but also that she felt safe and was not afraid of the alleged perpetrator. The facility's records indicated that the incident was reported to the nurse, who then notified the administrator, local police, the resident's family, and the medical doctor. The alleged perpetrator, a resident with moderate cognitive impairment and a documented history of sexually inappropriate behaviors toward staff, denied any inappropriate contact with the reporting resident. Progress notes detailed multiple prior incidents of sexual and physical aggression by this resident toward staff, including attempts to touch private areas and making inappropriate comments. Despite these documented behaviors, the facility's abuse investigation did not include an interview with the alleged perpetrator, and there was insufficient documentation of interviews with other staff or residents who may have had relevant information. The final abuse investigation report concluded there was insufficient evidence to declare intentional abuse, but lacked comprehensive documentation of the investigative process. Only a limited number of individuals were interviewed, and there were no notes specifying who was interviewed, when, or by whom, beyond a few named staff and residents. The investigation file provided by the administrator did not validate that a thorough and complete investigation was conducted, as required.