Failure to Investigate and Document Alleged Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough and timely investigation following an allegation of sexual abuse involving two residents, one of whom was non-verbal, quadriplegic, and completely dependent on staff for care. The incident occurred when a CNA observed one resident masturbating and rubbing his hand on the face of the non-verbal resident, who was unable to defend himself and appeared to be in distress. The CNA immediately intervened, separated the residents, and reported the incident to an LPN, who also recognized the seriousness of the situation and contacted the facility Administrator. Despite the immediate actions taken by staff to separate the residents and notify the Administrator, the facility did not complete a formal investigation into the incident. There was no documentation in the clinical records for either resident regarding the incident, including the absence of care plan updates, incident reports, or resident assessments. The care plan for the resident exhibiting hypersexual behavior was not updated until several days after the incident. Additionally, there was no evidence of timely family notification or a comprehensive review of the situation as required by facility policy. Interviews with staff and review of facility policy confirmed that the expected procedures following an allegation of abuse—such as reporting to the appropriate agencies, completing a facility investigation, updating care plans, and documenting the incident—were not followed. The lack of a prompt and thorough investigation, as well as insufficient documentation and care plan updates, constituted a failure to respond appropriately to the alleged violation.