Failure to Timely and Thoroughly Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an alleged incident of resident-to-resident sexual abuse involving two residents in the memory care unit. The incident occurred when a female resident wandered into a male resident's room, resulting in potential inappropriate contact. Although the residents were separated and full body assessments were eventually completed, these assessments were not performed immediately after the incident. Additionally, 15-minute safety checks for both residents did not begin until over two hours after the event. The facility's investigation was incomplete, as it did not include statements from all staff present during the incident, such as a CNA and an RN, nor did it incorporate a late entry note detailing the event. Furthermore, the investigation did not collect additional information from key staff or include all relevant documentation. The facility's policy required immediate initiation of the investigation, direct supervision of the resident alleged to have initiated the abuse, and prompt reporting to the state health department. However, the staff member responsible for coordinating the investigation did not provide further instructions or come to the facility on the night of the incident, and did not ensure that all necessary statements were collected. There was also a delay in notifying the nurse practitioner about the incident. Additional information provided by a CNA regarding the nature of the contact was not included in the investigation submitted to the state, and the facility did not ensure that the state was made aware of this information in a timely manner.