Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not ensure that an alleged incident of sexual abuse involving a resident was properly investigated. According to the facility's policy, all allegations of abuse, including sexual abuse, must be promptly and thoroughly investigated, with appropriate notifications made to authorities and documentation of all investigative steps. However, when an allegation was made that one resident put their hands down another resident's pants in a common area, the facility did not conduct a documented investigation as required by policy. The Administrator relied on a review of camera footage, which was later stated to be unavailable, and determined the allegation was unsubstantiated without further inquiry or reporting to the state survey agency or law enforcement. The resident involved in the alleged incident had significant cognitive impairment, as evidenced by a BIMS score of zero and diagnoses including dementia with agitation, senile degeneration of the brain, and major depressive disorder. The resident was also receiving hospice services and required assistance with activities of daily living. The alleged perpetrator had a history of making inappropriate sexual comments and was placed on one-to-one supervision following the incident. Despite these factors and the facility's policy requiring investigation and reporting, the Administrator did not initiate a formal investigation or notify external authorities. Interviews with staff and the resident's family revealed inconsistencies in the facility's response. The family was informed by nursing staff that the incident had been witnessed by others and that an assessment found no injuries or signs of distress. However, the Administrator later stated there was no camera footage and that the incident did not warrant reporting or further investigation. The lack of a documented investigation and failure to follow established protocols resulted in a deficiency related to the facility's handling of abuse allegations.