Failure to Investigate and Protect Residents Following Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for three of eight residents reviewed. Specifically, on three separate occasions, a resident with severe cognitive impairment was witnessed by visitors and/or staff engaging in sexually inappropriate behavior with two other residents who also lacked capacity to consent. There was no documented evidence that these incidents were thoroughly investigated to determine if abuse occurred or that measures were put in place to protect residents from further abuse during the investigation process. The facility's policy required immediate reporting and thorough investigation of any suspected abuse, including obtaining witness statements, assessing the residents involved, and notifying appropriate supervisory staff. However, for the incidents in question, documentation was incomplete or missing. For example, one incident report was not completed, and the investigations that were provided included only summaries and unsigned witness statements. There was no evidence that family members who witnessed the events were interviewed, and staff who were present were not always asked to provide statements. Additionally, there was no documentation of how abuse was ruled out or what interim protective measures were implemented for other residents during the investigation. Interviews with staff and administration revealed inconsistencies in the reporting and investigation process. Some staff were told not to document the incidents, and the Director of Nursing acknowledged that investigations were incomplete, with missing witness statements and assessments. The Administrator and Director of Nursing were not always notified of incidents in a timely manner, and there was uncertainty about whether families were informed. The lack of thorough investigation and documentation resulted in Immediate Jeopardy and Substandard Quality of Care for the residents involved.
Removal Plan
- Facility hall monitors were instated for all three shifts to ensure residents stayed out of other resident rooms
- All residents in the facility were assessed for aggression risk
- Resident #1 was placed on a 1:1
- All staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse
- Staff education was completed online, and multiple department facility staff working were interviewed and were able to demonstrate understanding of the education