Failure to Thoroughly Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse involving a moderately cognitively impaired resident with hemiplegia and muscle weakness. The incident was reported after the resident's husband received a voicemail from another resident stating that a male resident had pulled down his wife's pants and touched her. The resident herself reported that her pants were pulled down in a common area after a smoke break, but she denied being touched in her private area and refused a hospital evaluation. The accused resident denied the incident, stating they were only joking, and there were no staff or other residents present according to his account. The facility's investigation was incomplete, lacking statements from staff who supervised or assisted with the smoke break, as well as from other residents who may have witnessed the event. Notably, the investigation did not include a statement from the roommate who initially reported the incident to the resident's husband, nor did it identify which staff members were present during the relevant time. The Director of Nursing and Administrator confirmed that no staff or additional residents were interviewed regarding the incident or any similar behaviors by the accused resident. Facility policy required that all alleged violations involving abuse be thoroughly investigated, including interviews with the resident, the accused, and all potential witnesses, such as staff and other residents present at the time. However, the investigation did not meet these requirements, as it failed to identify or interview key individuals who may have had relevant information about the incident. The police were not contacted, and the incident was ultimately deemed unsubstantiated without a comprehensive investigation.