Failure to Investigate Alleged Sexual Abuse Between Residents
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving two residents, one of whom lacked the capacity to consent due to severe cognitive impairment. The incident involved one resident kissing another resident and attempting to climb into the resident's bed. Documentation showed that the resident who was kissed was dependent on staff for personal hygiene, mobility, and had a history of hemiplegia, hemiparesis, and aphasia, further indicating a lack of capacity to consent. The other resident involved also had severe cognitive impairment and required assistance with transfers. Progress notes documented the incident but did not indicate that any investigation was conducted, nor were interviews with the residents or potential witnesses performed. Staff, including the assigned RN and CNA who witnessed the event, confirmed that no investigation or written statements were completed. The DON acknowledged that the facility's policy defined nonconsensual sexual contact as sexual abuse and required investigation, but stated that no investigation was initiated because the resident who initiated the contact had forgotten the incident and there were no complaints from residents or their representatives. The facility's abuse coordinator and investigator was not notified of the incident, and no investigation was conducted as required by the facility's policy. The policy specified that all allegations of abuse, including resident-to-resident altercations, must be investigated objectively, timely, and completely, with written findings reported to the department of public health within five days. This process was not followed in this case.