Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to implement its policy and procedure regarding abuse when an allegation of sexual abuse was made by a resident. The incident involved a resident with moderate cognitive impairment and multiple medical diagnoses, who reported that another resident entered her room, tickled her foot under her blanket without consent, and left when told to stop. The resident expressed that she did not consent to the contact and believed the other resident wanted to have sex with her. The incident was reported to a CNA the following morning, who then informed an LVN, and subsequently, the matter was escalated to an RN and the facility administrator. Despite the report being relayed through appropriate staff channels, the administrator, who also served as the abuse coordinator, did not consider the incident to be sexual in nature and therefore did not initiate a thorough investigation or complete the required five-day follow-up investigation report. The administrator's decision was based on her personal assessment of the situation, rather than following the facility's written policy, which mandates that all allegations of abuse be thoroughly investigated and documented, with findings reported to the appropriate authorities. Interviews with staff indicated that both the LVN and RN considered the incident to be a possible case of sexual abuse, as the contact was non-consensual and made the resident feel uncomfortable and distressed. The facility's policy, reviewed during the investigation, clearly states that all allegations of abuse must be reported, investigated, and documented, regardless of the administrator's personal judgment. The failure to follow these procedures resulted in the deficiency cited by surveyors.