Failure to Complete Full Body Assessment After Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse for one resident with severe cognitive impairment. The resident, who had diagnoses including dementia with anxiety, generalized anxiety disorder, and chronic kidney disease, reported being sexually assaulted by a man. The facility's policy required an immediate full body skin assessment to be completed and documented by the nursing supervisor in such cases. However, after the allegation was made, only the resident's arm was assessed by the DON and nurse practitioner, as the resident mentioned arm pain. No full body or peri area skin assessment was performed or documented, despite the policy and the nature of the allegation. Interviews with staff confirmed that a comprehensive skin assessment was not completed. The LPN stated that no full body assessment was done, and the DON acknowledged that, in hindsight, a full assessment should have been performed. The facility did notify law enforcement and the resident's POA, and the resident was interviewed by the social worker, but the investigation lacked the required thorough physical assessment to check for signs of trauma or injury related to the alleged abuse.