Failure to Investigate and Respond to Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and respond to an allegation of inappropriate sexual behavior between two residents. One resident with severe cognitive impairment and another with moderate cognitive impairment and a history of psychiatric illness were found alone in the dining room, where a certified nursing assistant (CNA) observed one resident massaging the other's chest and discovered that the cognitively impaired female resident's brief was removed. The CNA intervened, removed the female resident from the situation, and notified the nurse. The incident was reported to the Director of Nursing (DON) and the Administrator, but the subsequent investigation was inconsistent and incomplete. The facility's investigation did not include a thorough review of the incident. The CNA's written and verbal statements were inconsistent, and the Administrator and DON determined that nothing had happened between the residents based on this discrepancy, despite physical evidence such as the removed brief and the residents being alone together. The Administrator described the investigation as a "soft investigation" and did not report the incident as abuse, nor did they notify the nurse practitioner of the potential sexual abuse. The medical provider was not informed of the incident until after state surveyors were present in the facility. Additionally, the facility did not separate the residents or provide increased supervision immediately following the incident, as required by their own abuse and neglect policy. The facility's policy required immediate and thorough investigation of all allegations of abuse, including interviews, medical assessments, and documentation. However, the investigation lacked key elements such as interviews with all relevant staff, timely notification of the medical provider, and adequate protection of the alleged victim. The failure to follow policy and thoroughly investigate the incident placed residents at risk for abuse and neglect, and led to the identification of Immediate Jeopardy by surveyors.