Failure to Investigate Sexual Abuse Allegation Leads to Repeat Incident
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving two residents, one of whom was severely cognitively impaired and non-verbal, dependent on staff for mobility, and unable to communicate or consent. A certified nursing assistant observed one resident with his hand inside the diaper of the cognitively impaired resident and reported the incident to an LPN, who then notified the facility administrator. The administrator reviewed video surveillance but, upon not seeing anything, did not pursue a further investigation. The care plan for the cognitively impaired resident did not address risk of abuse or neglect, and the other resident's care plan, which noted a history of inappropriate contact, was not updated with interventions until after a subsequent incident. The day following the initial uninvestigated allegation, the same resident was found in the room of the cognitively impaired resident, attempting to get into bed with her. Documentation and staff interviews confirmed that the resident admitted to entering the room and attempting sexual contact. The facility's abuse prevention policy requires prompt and thorough investigation of all abuse allegations, but this was not followed. Additionally, a police report was filed by an anonymous caller who alleged that multiple incidents of abuse were occurring and not being reported by the facility.