Failure to Protect Residents from Alleged Sexual Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from alleged sexual abuse, resulting in Immediate Jeopardy for two residents with intact cognition. Both residents reported inappropriate actions by a Certified Nursing Assistant (CNA), including sexually inappropriate comments and unwanted touching during personal care. Despite these allegations, there was no documented evidence that a thorough investigation was initiated, nor were the residents assessed by a registered nurse or provided with a psychosocial evaluation after expressing fear and discomfort. One resident, diagnosed with multiple sclerosis, protein calorie malnutrition, and pseudobulbar affect, reported that a male CNA made a sexually inappropriate comment and applied cream to intimate areas without proper consent. The resident had previously requested female caregivers, but this preference was not documented or honored. The incident was reported to facility leadership, but the CNA was only suspended for three days without a comprehensive investigation and was later allowed to return to work with access to all residents. There was no documentation of a physical or psychosocial assessment for the resident following the incident. A second resident, with diagnoses including type 2 diabetes, depression, and anxiety disorder, reported that the same CNA took an unusually long time wiping their genital area, making them feel unsafe. This concern was reported to another CNA and a registered nurse supervisor, but no formal investigation or assessment was conducted. The resident was transferred to another room, but there was no evidence of a registered nurse assessment or psychosocial evaluation. Facility leadership decided not to report or investigate the allegation, citing a lack of perceived sexual abuse, and the medical director was not informed until much later.