Failure to Investigate and Report Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to identify and initiate a thorough investigation into an alleged violation of abuse involving two residents with dementia. On the evening in question, a Certified Resident Care Assistant (CRCA) discovered one resident in another resident's room, with one resident touching the other's breast and thigh while the latter was not wearing pants. The CRCA separated the residents and reported the incident to the Registered Nurse (RN) on duty, who then notified the Assistant Director of Health Services (ADHS). However, the full details of the incident, including the inappropriate touching and the lack of clothing, were not accurately communicated up the chain of command. The RN and ADHS both failed to recognize the incident as potentially reportable abuse, relying on incomplete information and not conducting a thorough investigation. The Executive Director (ED) was not notified, and the CRCA was not interviewed or asked to provide a written statement about what she witnessed. The facility's documentation of the event was incomplete and did not reflect the severity of the situation, as the notes only mentioned hands on the leg and shoulder, omitting the more serious details reported by the CRCA. Both residents involved were documented as having severe cognitive impairment and lacking capacity to consent to intimate contact. Despite this, the facility did not initiate a formal investigation, did not report the incident as required, and did not follow its own abuse, neglect, and exploitation procedural guidelines. No reportable incident was filed with the state, and management staff were unaware of the full extent of the incident until interviewed during the survey.