Failure to Timely and Thoroughly Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly and timely investigate multiple allegations of resident-to-resident sexual abuse, affecting four residents. In one incident, a resident with severe cognitive impairment and a history of sexually inappropriate behavior was observed sitting on another resident's lap and kissing him. Staff separated the residents and provided education on personal boundaries, but the incident was not immediately reported to administration. The Director of Nursing (DON) only became aware of the event two days later during a routine review, and the state-required Self-Reported Incident (SRI) was not filed until four days after the incident. The facility's investigation did not include timely interviews or witness statements from staff involved, and the residents involved did not recall the incident when later interviewed. In another event, two residents were observed engaging in sexual activity in a public area, specifically the smoking porch, in view of other residents. Staff intervened and explained the inappropriateness of the behavior, but the residents dismissed the staff's concerns. Despite the incident being reported to the DON the following day, no investigation was initiated until several weeks later. The facility did not immediately assess the residents' capacity to consent or report the incident to the state agency as required. The DON later confirmed that the decision not to file an SRI was based on an assumption of consent, without proper investigation. The facility's policy required immediate investigation and thorough documentation of all abuse allegations, including identification of responsible staff, interviews with all involved parties, and a focus on determining the occurrence and extent of abuse. However, in both incidents, the facility failed to follow these procedures, resulting in delayed and incomplete investigations. The lack of timely reporting, failure to obtain staff and witness statements, and inadequate assessment of resident capacity to consent contributed to the deficiency.