Failure to Conduct Comprehensive Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a comprehensive investigation into an allegation of sexual abuse involving two residents. Staff discovered one resident standing at the head of another resident's bed with his pants lowered to his knees, exposing his buttocks, while the other resident was asleep and facing him. The staff member who discovered the incident questioned the resident, who immediately pulled up his pants and replied that he was doing nothing. Video surveillance confirmed that the resident was alone in the other resident's room with the door closed for eight minutes, and exited the room with his pants not fully pulled up. There was no staff present in the hallway during this period. Interviews with staff revealed that the resident who entered the room was known to wander, enter other residents' rooms, and take their belongings. Staff expressed concerns that this may not have been the first such incident. The resident was described as cognitively intact, aware of boundaries, and able to converse, but continued to exhibit wandering and inappropriate behaviors. The facility did not have an individualized plan to address these behaviors beyond standard monitoring. The resident who was found in bed was severely cognitively impaired, dependent on staff for all activities of daily living, and unable to verbalize needs. The facility's investigation was incomplete. While staff checked the resident in bed for skin issues and documented this, there was no documentation of a thorough assessment for possible physical contact or environmental evidence. The investigation did not include a review of the video surveillance footage as part of the process, nor did it explore the cause of the resident's presence in the other resident's room or review the resident's wandering behavior. The facility concluded the allegation was unsubstantiated without completing all required investigative steps.