Failure to Investigate and Document Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving two residents. According to interviews and record review, a CNA reported to the DON that one resident entered another resident's room and made inappropriate sexual requests. The DON completed a capacity for sexual consent assessment for both residents and instructed the resident not to ask such questions again. However, there was no documentation of the incident or the investigation, despite the facility's policy requiring such documentation. Further, it was reported that the resident who was approached may have exposed herself, but this was also not documented or investigated thoroughly. Interviews with the DON, Administrator, and Regional President of Operations revealed that while the incident was discussed among staff and both residents were interviewed, there was no formal documentation or evidence of a comprehensive investigation. The facility's policy mandates that any suspicion of non-consensual sexual relations or questions about a resident's capacity to consent should trigger an investigation, with findings documented in the resident's record. In this case, the required documentation and investigative steps were not completed.