Failure to Implement Abuse Prevention Policy and Investigate Allegations
Penalty
Summary
The facility failed to implement its abuse prevention policy through adequate prevention, reporting, and investigation of abuse allegations involving two residents. One resident with a history of traumatic brain injury and moderate cognitive impairment was known to display sexually inappropriate behaviors and was on 15-minute checks for monitoring. Despite this, staff interviews revealed ongoing incidents of inappropriate touching involving both staff and other residents. Another resident, also moderately cognitively impaired, reported being touched in the genital area by the first resident near the nurse's station. This allegation was corroborated by staff observations and the resident's emotional distress following the incident. The facility's investigation into the reported abuse was incomplete, lacking interviews with relevant staff and residents. Although documentation indicated that certain residents were interviewed, direct interviews with those residents revealed that some had not actually been questioned about the incident. Additionally, the staff member listed as having reported the abuse denied knowledge of the allegation and did not report it to the administrator. The administrator acknowledged that it was problematic for residents to claim they were not interviewed as part of the investigation. A third resident, who was cognitively intact, reported a separate incident in which the same resident with a history of inappropriate behavior grabbed her sweater and offered money for sexual favors. This allegation was reported to staff at the time but was not investigated or reported by the administrator, who did not consider the incident to be sexual abuse due to the lack of physical contact. The facility's abuse prevention policy defines abuse broadly, including both physical and mental abuse, and requires all allegations to be reported and investigated within required timeframes.