Failure to Investigate and Protect Residents Following Alleged Sexual Abuse
Penalty
Summary
The facility failed to identify and investigate an allegation of sexual abuse involving two residents who reported that another resident made sexually explicit remarks and unwanted advances toward them. Despite the residents expressing fear and distress, and reporting the incidents to multiple staff members, including an activities aide and several certified nurse aides, the allegations were not promptly reported to management or nursing leadership as required by the facility's abuse prevention policy. The staff members who received the initial complaints either deferred responsibility, failed to escalate the concerns, or dismissed the urgency of the situation, resulting in a lack of immediate protective measures for the affected residents. The residents involved had documented histories of trauma and mental health conditions, including anxiety, schizophrenia, major depressive disorder, and post-traumatic stress disorder. Both were assessed as cognitively intact and had no recent behavioral symptoms according to their medical records. The alleged perpetrator also had a history of sexually inappropriate behavior documented in his care plan, yet no immediate action was taken to separate him from the complainants or to initiate an investigation when the allegations were first reported. Instead, the residents were advised to avoid the alleged perpetrator and to report the matter to management at a later time, leaving them unprotected and causing them to withdraw from social activities and remain isolated in their rooms. Multiple staff statements confirmed that the allegations were not investigated in a timely manner, and that management was not notified promptly. Written statements from the certified nurse aides were not followed up with interviews or further inquiry by facility leadership. The administrator and social services director did not initiate an investigation or increase monitoring of the alleged perpetrator until days after the initial report. This failure to respond appropriately to the allegations resulted in the residents continuing to experience fear and distress, and led to a finding of Immediate Jeopardy by surveyors.