Failure to Investigate and Protect Residents from Repeated Sexual Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation and ensure protection from further allegations of sexual abuse involving three residents. Resident C, who had diagnoses including vascular dementia, depression, and severe cognitive impairment, was placed on 15-minute safety checks for sexually acting out, but there was no documentation explaining the behaviors that led to this intervention. On two separate occasions, Resident C was reported to have inappropriately touched female residents during or after smoke breaks. Despite these reports, the facility did not complete comprehensive interviews or investigations with all involved residents and witnesses. Resident B, who was moderately cognitively impaired and had a history of anxiety and depression, reported being touched inappropriately by Resident C while being wheeled inside after a smoke break. Another resident witnessed the incident and corroborated the report. Resident B expressed feeling uncomfortable, upset, and fearful that Resident C might enter her room at night. Similarly, Resident G, also moderately cognitively impaired, reported that Resident C had touched her inappropriately on more than one occasion and that she had informed staff, but could not recall their names. Resident G stated that these behaviors continued to occur, particularly during transitions from the smoking area, and that management had not interviewed her about the incidents. Interviews with staff, including the DON, LPN, and RN, revealed uncertainty about the reasons for Resident C's monitoring and a lack of follow-up on the initial and subsequent allegations. The facility's abuse policy required a thorough investigation, including interviews with all involved parties and witnesses, but this was not completed. The lack of comprehensive investigation and failure to ensure resident protection resulted in repeated incidents and ongoing anxiety and fear among the affected residents.