Failure to Implement Protective Measures Following Abuse Allegation
Penalty
Summary
The facility failed to implement protective measures for a resident following an allegation of sexual abuse by staff during toileting assistance. The resident, who had a history of schizophrenia, bipolar disorder, major depressive disorder, intellectual disability, anxiety, and hallucinations, made an accusation of sexual abuse. Despite the facility's policy requiring immediate suspension and removal of the accused staff member pending investigation, there was no evidence that the alleged perpetrator was removed from the facility or denied access to residents during the investigation. Staff continued to provide care to the resident without following the care plan directive to use two staff members during care, and some staff were unaware of this requirement. The resident's care plan indicated a need for close monitoring and the use of two staff members during care due to behavioral issues and a history of making false accusations. However, observations and staff interviews revealed that care was provided by a single CNA and that both direct care staff and licensed nursing staff were unaware of the two-person care requirement. Administrative staff also reported being unaware of the need to suspend or remove the accused staff member during the investigation, despite being notified of the allegation and initiating an investigation promptly.