Failure to Investigate and Protect Residents Following Alleged Sexual Abuse
Penalty
Summary
The facility failed to initiate investigative protocols and protective interventions in response to allegations of resident-to-resident sexual abuse involving two cognitively impaired residents and another resident with intellectual disabilities. On the day in question, one resident was found in another resident's room with the latter exposing himself, while the first resident had saliva on his face and mouth. Later that same day, another resident was found with feces and blood on his shirt and brief, while the same alleged perpetrator was in the room performing self-gratification. Staff observed these incidents and reported them to a qualified medication aide (QMA), but there was confusion regarding the chain of command and the appropriate steps to take. The QMA and other staff were not trained in interviewing residents about abuse, and their actions did not follow established protocols for abuse investigation. The facility's documentation and communication regarding the incidents were incomplete and inconsistent. The clinical records for the involved residents lacked documentation of the events, and skin assessments performed did not address the genital or rectal areas as would be expected in cases of alleged sexual abuse. The facility's self-reported incident to the state did not indicate an allegation of sexual abuse, and the administrator did not include this information in the report. Family members of one resident were informed of the incident by anonymous staff calls rather than by the facility, leading to concerns about transparency and a possible cover-up. The facility's abuse prevention policy required immediate notification of leadership, documentation, and reporting to state agencies, but these steps were not fully followed. Interviews with staff revealed that several employees, including CNAs, QMAs, and nurses, were involved in responding to the incidents but did not consistently communicate the nature of the events or follow the facility's abuse protocols. Some staff attempted to interview residents without proper training, and there was a lack of clarity about who was responsible for initiating an investigation. The administrator and DON were not fully informed of the sexual nature of the incidents until after the family contacted the police. The facility did not complete a comprehensive review of their abuse policy and procedures, and the events were not properly documented or investigated according to regulatory requirements.