Failure to Thoroughly Investigate and Substantiate Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and identify sexual abuse after receiving and investigating three separate allegations against a certified nursing assistant (CNA). Three residents, all of whom were cognitively intact and had the capacity to make decisions, reported that the CNA inappropriately touched them during personal care. Each resident described specific incidents where the CNA engaged in non-consensual sexual contact, including rubbing and inserting fingers into their vaginal area. The residents reported feeling uncomfortable, humiliated, and taken advantage of, and two expressed concern that there may be other victims. Despite these detailed allegations, the facility's investigations into each incident were incomplete. The investigative summaries for each resident did not include clarifying questions to fully understand the nature of the alleged abuse. The DON acknowledged during interviews that she did not clarify what the residents meant by terms such as "uncomfortable experience" or "inappropriate touch" during her interviews. As a result, the facility concluded that the allegations were unsubstantiated without thoroughly exploring the residents' statements or the context of the alleged incidents. Additionally, the facility's review of the CNA's pre-employment references was flawed. The investigative summaries indicated only positive references, but the CNA's personnel file contained two negative references, both stating the CNA was unreliable and would not be rehired. The DON and ADM admitted they had not seen these negative references during the hiring process or the subsequent investigations. The facility's failure to properly review and verify the CNA's references, combined with the lack of thorough investigation into the residents' allegations, resulted in a failure to identify and substantiate sexual abuse within the facility.