Failure to Investigate Resident's Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse made by a resident with metabolic encephalopathy and schizophrenia, who was assessed as having moderately impaired cognition and requiring substantial assistance with activities of daily living. On the morning in question, staff responded to yelling and found the resident in another resident's room, where she struck him with a water pitcher and accused him of rape. Multiple witnesses, including a roommate and a CNA, confirmed hearing the resident make the allegation, and staff documented her aggressive behavior and need for one-to-one monitoring following the incident. Despite being aware of the allegation, the Director of Nursing did not document or conduct a thorough investigation into the claim, relying instead on his own assessment that the accused resident could not have committed the act due to his physical limitations. The facility's policy required immediate investigation and documentation of all abuse allegations, including interviews and chronological records, but no such documentation was provided for this incident. This failure resulted in the inability to determine whether the alleged abuse occurred.