Failure to Conduct Complete Investigation and Reporting of Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure a complete and accurate investigation into an alleged incident of sexual abuse involving a resident with severe cognitive impairment. According to the facility's abuse policy, all reports of abuse must be promptly reported to appropriate agencies and thoroughly investigated. However, after an activities aide reported witnessing one resident grab another resident's breast and genital area during an activity, the only written statement obtained was from the reporting staff member. No additional written statements or interviews from other staff or alert and oriented residents present at the time were included in the investigation file. The Director of Nursing (DON) concluded that the incident was not reportable due to both residents being incapable and the absence of injury, despite an eyewitness account describing inappropriate touching. The facility did not document any efforts to interview other potential witnesses or follow up on the eyewitness account, nor did it report the incident to the Department of Health as required by policy and federal regulations. Interviews with the DON and Nursing Home Administrator confirmed that they did not believe the incident was reportable and were unable to provide evidence that the investigation was complete or compliant with facility policy and regulatory requirements. The resident involved had a diagnosis of dementia and was assessed as severely cognitively impaired at the time of the incident.