Failure to Investigate and Report Alleged Sexual Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to thoroughly investigate and respond to allegations and incidents of sexual abuse involving three residents who were identified as vulnerable and unable to consent to sexual activity due to cognitive deficits. Staff observed incidents where one resident was found unclothed with another resident performing oral sex, and another incident where a resident's pants and brief were found open in the presence of another resident. Despite staff being aware of these events, they did not identify them as potential abuse, did not initiate protective measures, and did not conduct behavioral assessments or root cause analyses related to the incidents. The facility did not document or report these events as required, failing to notify law enforcement, Adult Protective Services, or the State Survey Agency. No facility-reported incidents or investigations were provided for review, and the facility did not follow abuse reporting requirements or thoroughly investigate the events. Staff interviews confirmed a lack of recognition of the incidents as abuse and a lack of appropriate response, including not ensuring the safety of residents who were unable to consent to sexual activity.