Failure to Implement Abuse Prevention and Investigation Policies
Penalty
Summary
The facility failed to implement its abuse prevention and investigation policies in response to allegations of sexual abuse involving two residents. According to the facility's own policies, the administrator is responsible for ensuring prevention of further abuse, and investigators are required to interview all relevant staff, residents, and witnesses, as well as review all events leading up to the alleged incident. However, the facility did not conduct a thorough investigation, did not report the incident to law enforcement, and did not ensure that all potentially affected residents were interviewed or assessed. Documentation shows that a male resident repeatedly entered female residents' rooms without consent, and staff observed and redirected him on multiple occasions, but no comprehensive investigation or protective measures were implemented as required by policy. Nursing notes and staff interviews revealed that the male resident was seen entering a female resident's room while a CNA was providing care, and another female resident reported similar behavior the previous night. Staff educated the male resident about not entering other residents' rooms, but there was no documentation of assessment or follow-up for the female resident involved in the incident. Multiple staff members, including CNAs and LPNs, reported the male resident's inappropriate behavior and expressed concerns about the lack of action taken by facility leadership. The facility did not notify the resident representative, did not interview other potentially affected residents, and did not implement additional interventions after repeated incidents. Interviews with facility leadership, including the unit manager, assistant director of nursing, and facility administrator, confirmed that no residents were interviewed regarding safety concerns after the incident, and there was no clear plan to ensure resident safety. The administrator was unaware of the documented behavioral concerns prior to the incident, and staff reported being instructed not to contact law enforcement or send the female resident for evaluation. The facility's failure to follow its own abuse prevention and investigation policies resulted in a lack of protection and support for residents involved in or potentially affected by the alleged abuse.