Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from abuse and neglect by not following its own policies after an allegation of sexual assault. The resident, who had moderate cognitive impairment, hemiplegia, hemiparesis, and required substantial assistance with toileting, reported an allegation of sexual assault. Despite the facility's policy requiring immediate assessment, notification, and protection, there was no documentation of a thorough assessment or skin check following the allegation. Additionally, the resident was not offered an emergency room evaluation after the report. The staff member accused in the allegation was not immediately suspended as required. Documentation showed that the staff member continued to work a full shift after the allegation was reported, and the suspension form was not reviewed with the employee until several days later. The investigation summary was unsigned and completed days after the incident, and staff statements were not obtained promptly. The facility also failed to ensure that interventions, such as female care only and care in pairs, were consistently implemented, as male staff continued to provide care and document treatments for the resident. A new skin tear was later discovered on the resident's labia, but there was no documentation of a thorough skin check or investigation into this injury of unknown origin. The injury was not reported to the state, and no further documentation or follow-up was found in the resident's record. Staff interviews confirmed that required reporting and investigation steps were not taken, and interventions to prevent further abuse were not consistently followed.