Failure to Investigate Sexual Assault Allegation and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual assault involving a resident with moderate cognitive impairment and significant physical limitations, including hemiplegia and hemiparesis. The resident reported to a therapist that a male CNA straddled them and reached into their pants with an ungloved hand. The facility's investigation did not include interviews or witness statements from the resident or staff who worked directly with the resident at the time of the alleged incident. Additionally, the investigation summary was unsigned, and there was no documentation of a thorough skin check or alert monitoring for psychosocial harm following the allegation. The staff member accused was not immediately suspended as required; instead, they continued to work a full shift after the allegation was reported. The suspension form was completed by the administrator without the staff member's knowledge or signature, and the staff member was not informed of the suspension until several days later. The staff member also stated that they were not interviewed or asked for a statement regarding the incident until after their scheduled days off, and only then received the suspension form. Further, there was no documentation that the resident's power of attorney or physician was notified of the allegation. A new skin tear was later found on the resident's labia, but this injury was not reported or investigated, and no thorough skin check was documented. The nurse manager acknowledged that the injury should have been reported and investigated due to its location and the recent allegation, but this did not occur. The investigation lacked critical elements such as timely suspension of the accused staff, comprehensive interviews, and proper documentation of resident assessment and notifications.