Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure timely reporting and thorough investigation of an allegation of sexual abuse involving a cognitively impaired male resident and a female resident with moderate cognitive impairment. The incident occurred when the female resident was awakened in her room by the male resident touching her back, arm, and stomach. She screamed, causing the male resident to leave, and subsequently reported the incident to another resident, who then informed an LPN. The LPN and another nurse were made aware of the allegation, but neither took immediate steps to ensure the safety of the resident or to prevent the alleged perpetrator from accessing other residents. Despite being informed of the incident, the assigned nurse did not perform a skin check on the alleged victim, did not complete an incident report, and only attempted to notify the DON via text message, which was not received until the following morning. The nurse did not escalate the report to the Administrator or follow up when the initial notification failed. The DON and Administrator delayed gathering statements from staff and did not initiate a full investigation, as they believed the event did not rise to the level of harm. The male resident continued to wander the hallways without supervision until the victim's sister insisted on further action. The facility's policies required immediate segregation of the alleged perpetrator, a thorough nursing evaluation, notification of the attending physician, and completion of an incident report upon any allegation of abuse. These procedures were not followed, as the staff failed to promptly report the incident to appropriate authorities, did not conduct required assessments, and did not initiate a comprehensive investigation. The lack of immediate and thorough response resulted in a delay in implementing corrective actions to protect residents.