Failure to Investigate Alleged Abuse Between Residents
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents, both with dementia and other significant medical conditions. An incident occurred in which a male resident was observed grabbing the back of a female resident's head and kissing her. The female resident was unable to recall the incident, and no signs of distress or injury were noted at the time. The event was witnessed by an activity aide, who reported it to the nurse in charge when it was safe to do so. The nurse notified the RN, who in turn notified the DON and NHA via text message. However, no formal investigation was initiated, and no documentation of interviews or further inquiry was completed. Staff interviews revealed that the incident was not reported to the State Agency, and the facility leadership decided not to investigate further because there was no apparent intent, injury, or recall of the event by the resident involved. The only witness, the activity aide, was spoken to by phone, but no written records or detailed accounts were maintained. The staff involved did not recall being instructed to investigate or notify additional parties, and there was a lack of clarity regarding who else may have witnessed the event or was present at the time. Additionally, observations showed that the male resident involved had a history of inappropriate touching and sexual comments toward other residents and staff. Despite this behavioral history and the incident in question, the facility did not initiate a timely or thorough investigation as required by their abuse policy. The policy mandates immediate initiation of an investigation and reporting to appropriate authorities, which was not followed in this case.