Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving three residents. One cognitively intact resident with a left ankle fracture reported that a male resident in a wheelchair entered her room uninvited, placed his hand under her blanket, and attempted to move his hand up her thigh. After she stopped him, the male resident moved to her roommate, who was severely cognitively impaired and dependent for all activities of daily living, and similarly reached under her blanket. The incident was witnessed by staff who responded to calls for help. The male resident involved had a documented history of severe cognitive impairment and repeated sexually inappropriate behaviors toward both staff and other residents, including multiple incidents of inappropriate touching and sexual comments. Despite this history and the specific incident involving two female residents, the facility did not conduct an investigation into the event as required by their abuse prevention policy. The administrator and staff confirmed awareness of the incident but acknowledged that no formal investigation was initiated. Documentation in the medical records and staff interviews confirmed that the incident was reported to facility leadership, and that the male resident's behaviors had been previously identified and care planned for monitoring and redirection. However, the lack of a thorough investigation into the specific allegations of abuse on the date in question constituted a failure to respond appropriately to alleged violations, as required by federal regulations and the facility's own policies.