Failure to Investigate Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to thoroughly and promptly investigate allegations of sexual abuse involving two residents, resulting in a deficiency identified during an abbreviated survey. According to the facility's abuse prevention policy, all allegations of abuse must be immediately reported and investigated, including obtaining statements from staff, witnesses, and residents, as well as reviewing medical and employee records. However, in both cases, there was no documented evidence that a comprehensive investigation was initiated to rule out abuse, neglect, or mistreatment. One resident, with a history of multiple sclerosis and intact cognition, reported that a male CNA provided intimate care despite their request for a female caregiver and made inappropriate comments regarding the resident's body. The resident delayed reporting the incident due to embarrassment, but when the family member informed facility leadership, the Assistant Director of Nursing dismissed the allegation, believing the resident was fabricating the story, and did not pursue further investigation. The administrator also concluded within two hours that there was no evidence of abuse based on family input, without conducting a thorough inquiry. A second resident, also with intact cognition and a care plan identifying risk for psychosocial distress, reported discomfort and distress after a CNA allegedly took an unusually long time providing care to their genital area. The resident was visibly upset and requested a room change to avoid further contact with the CNA. Although the concern was reported to nursing and social work staff, no further questions were asked, and the Director of Nursing decided not to report or investigate the allegation, concluding it did not constitute sexual abuse. The administrator similarly determined no investigation was necessary. The medical director later stated that all allegations of abuse should be reported and investigated immediately.