Failure to Investigate Allegations of Abuse and Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to implement its policies and procedures for investigating allegations of abuse involving four residents. Despite having a policy that requires all allegations to be thoroughly investigated, the facility did not conduct comprehensive interviews or document investigations after multiple reports of inappropriate sexual behavior by a resident with a known history of such actions. For example, only a subset of nurse aides and licensed nurses who provided care to one of the affected residents were interviewed, and there was no evidence of interviews or observations with other potentially affected residents. Multiple staff members reported witnessing or hearing about the resident's sexually inappropriate behaviors, including touching, kissing, and entering other residents' rooms without consent. These behaviors were reported to facility administration and the DON, but the facility's incident logs did not include documentation or investigations related to these reports. Staff interviews revealed that the behaviors were ongoing, widely known among staff, and that some staff were told by management to disregard or minimize the incidents. The clinical records and incident lists reviewed showed a lack of documentation for several reported incidents involving different residents, including those who were unable to communicate. Staff expressed concerns that the administration was aware of the behaviors for months but failed to act according to policy. The deficiency resulted in a resident with a known history of sexually inappropriate behavior continuing to touch non-consenting residents without proper investigation or intervention.