Failure to Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of sexual abuse made by a resident. The resident, who had moderate cognitive impairment and was dependent on staff for care, reported being sexually assaulted by a male staff member matching the description of an agency employee. The incident was reported to facility leadership, and the staff member in question was identified as having worked in the area during the relevant time period. Despite the resident's detailed account and the staff member's presence in the facility, the facility did not complete a comprehensive investigation. Interviews and record reviews revealed that the facility did not interview all potentially involved parties, including other residents who may have been affected, nor did they thoroughly document the investigation process. The facility's leadership relied on inconsistencies in the resident's account and the belief that the alleged perpetrator was not present at the time of the incident as reasons not to pursue a full investigation. No further assessment of other residents or follow-up interviews were conducted after the resident was transferred to the hospital. Key staff members, including the Administrator, Medical Director, and Social Services Director, confirmed that no comprehensive investigation took place. The staffing agency was not notified of the incident, and there was no evidence of a root cause analysis or efforts to determine if other residents were at risk. The lack of a thorough investigation and failure to follow facility policy and regulatory requirements resulted in a finding of Immediate Jeopardy and substandard quality of care.
Removal Plan
- Staff who were not available during the training will be trained before being allowed to work, and must attain a 100% score on competency verification; retraining will be provided if the score is less than 100%.
- Staff provided with education/re-education & competency verification on sexual abuse and evidence protection.
- Any concerns identified during staff interviews will be addressed by the DON/Administrator.
- Facility actions include providing additional training, conducting additional interviews as part of the investigation, conducting root cause analysis of any concern identified, and reporting to QAPI committee any patterns and trends identified.
- The QAPI team developed an abuse/neglect quality assurance tool to review all incidents and allegations of abuse/neglect.
- QAPI team review of all allegations and incidents to ensure thorough investigation, immediate removal of alleged perpetrator, prompt reporting to Administrator and state agency, notification of law enforcement, adherence to abuse/neglect protocol, and implementation of interventions to ensure resident protection.
- QAPI team will discuss patterns/trends during Ad-Hoc and scheduled monthly QAPI meetings, including members of the governing body and executive management team when investigating any allegation of abuse/neglect.
- Residents able to participate were interviewed to ensure they feel safe; results documented in Resident Abuse Interview. Residents unable to participate were assessed by nurses for signs of abuse/neglect.
- Ad-Hoc QAPI meeting with leadership team to discuss the deficiency and corrective actions.
- Policies and procedures related to investigation of allegations of abuse/neglect were reviewed by leadership; no revision needed.
- Leadership team provided with training by Regional Regulatory Compliance Officer regarding investigation process, resident protection, and compliance monitoring.
- Significant Event Call (SEC) process implemented for review of abuse/neglect allegations, including participation by facility leadership and executive management.
- Staff provided with training on responsibility to participate/cooperate in investigations, abuse policy, and prevention of resident abuse/neglect; posttests requiring 100% score.
- Agency staff, if used in the future, will receive the same training and competency verification as facility staff.
- DON/NHA and IDT will conduct daily clinical meetings to discuss residents with new or worsening behavior/cognition and ensure care plans are developed and concerns addressed immediately.
- DON/NHA/Charge nurse/MOD will review residents with worsening behavior/cognition to ensure care plans and immediate action.
- DON/Administrator will review/audit all incidents/potential abuse daily to ensure compliance with investigation of allegations of abuse.
- Ad-Hoc QAPI meetings to review results of observations and monitoring activities related to prevention of elopement and abuse, with follow-up on concerns and additional interventions as needed, for a minimum of three months.
- Monthly QAPI meetings to discuss facility actions related to investigation of abuse/neglect, determine need for additional interventions or corrective actions, and review results of monitoring activities.