Failure to Immediately Investigate and Protect After Allegation of Inappropriate Physical Contact
Penalty
Summary
The facility failed to immediately provide protections and initiate an investigation after a resident reported unwanted and inappropriate physical contact from another resident. One resident, with diagnoses including alcohol dependence and bipolar disorder, reported to the social service designee (SSD) and the director of nursing (DON) that another resident sat on his lap and kissed him, despite his request for her to stop. The incident was documented in a progress note, but no immediate changes were made to the care plan, and safety interventions such as 15-minute checks were not implemented until several days later. The resident's care plan did not reflect any updates following the incident, and the resident continued to have direct proximity to the alleged perpetrator. The facility did not initiate an immediate investigation or interview other residents who may have witnessed the event. The SSD and DON did not further discuss the allegation or notify other staff to begin an investigation, contrary to facility policy requiring prompt reporting and investigation of abuse allegations. The alleged perpetrator, who had a history of impulsive and non-consensual touching, did not have her care plan updated until after the incident was reported to police. Documentation of safety checks for both residents was incomplete, and there was a lack of evidence that appropriate monitoring or protective interventions were put in place immediately following the report.