Failure to Investigate Alleged Sexual Abuse Between Residents
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with severe cognitive impairment who was observed being fondled by another resident. Multiple staff members, including CNAs and an RN, witnessed or were informed of the incident in which one resident was seen grabbing another resident's breasts in the activity room. The incident was reported among staff, and measures were taken to separate the two residents during activities. However, there was no evidence that the incident was reported to the Nursing Home Administrator or that a formal investigation was initiated, as required by facility policy. The affected resident was nonverbal and used nonverbal cues to communicate, while the resident who committed the act had a history of inappropriate behavior and severe cognitive impairment. Despite staff awareness and documentation of the incident, the facility did not complete an incident report or conduct an investigation. The facility's abuse policy required immediate investigation and reporting of all alleged violations, but this process was not followed in this case.