Failure to Conduct Thorough Investigation of Alleged Sexual Assault
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged sexual assault involving a resident with severely impaired cognitive skills, who was admitted with multiple diagnoses including a urinary tract infection, Parkinson's disease, fibromyalgia, and dystonia. The resident, who was incontinent of bowel and bladder, reported to her daughter that she had been raped by a male staff member. The allegation was reported to the facility, and a self-reported incident was created. The resident described the alleged perpetrator as a short man with short black hair, but the only male CNA on duty did not match this description, and no other males were present according to the staff schedule and employee list. The resident was assessed, and no immediate signs of abuse were found, though a full body assessment later revealed multiple bruises and a hematoma. The facility's investigation was limited in scope. Only staff working the night shift on the date of the alleged incident were interviewed, and staff who provided care during the following day were not questioned about the resident's condition or demeanor. Statements from key staff, including the accused CNA, were not obtained until several days after the incident, and the investigation did not address new findings of bruising to the back of the resident's knees. Documentation of the bruising was incomplete, lacking photographs, measurements, or detailed descriptions. The facility's policy required interviews with all relevant witnesses and thorough documentation, but these steps were not fully followed. The resident was ultimately sent to the hospital for examination, where a rape kit was performed, and a police report was filed by the family. The family also requested additional safety measures for the resident. Despite these actions, the facility's internal investigation did not meet its own policy standards for thoroughness, as it failed to interview all potentially relevant staff, did not fully document physical findings, and delayed obtaining statements from involved personnel. The deficiency centers on the incomplete and insufficient investigation of the abuse allegation.