Failure to Investigate and Ensure Safety After Alleged Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an incident of alleged sexual abuse involving two residents. One resident with moderate cognitive impairment and ambulatory status was found half naked on top of another resident, with their mouth on the other resident's genital area. The facility's abuse and incident investigation policies required thorough assessment and reporting, including head-to-toe assessments and hospital evaluations for involved residents. However, there was no documented evidence that these assessments were performed for either resident, nor that both residents were transferred to the hospital for medical evaluation as required by policy and as instructed by the Director of Nursing. The incident was reported to administration, law enforcement, and the Department of Health. Nursing notes indicated that one resident was to be placed on 1:1 monitoring and the other was to be sent to the emergency room, but documentation did not confirm that these actions were carried out. Interviews with facility staff, including the Assistant Director of Nursing and the Medical Director, confirmed that both residents should have been assessed and transferred to the hospital, but this did not occur. There was also no evidence that 1:1 monitoring was implemented for the resident as indicated in the investigative summary. Both residents involved had significant cognitive impairments and required varying levels of assistance with activities of daily living. The facility's failure to conduct thorough assessments, ensure hospital evaluations, and document required monitoring and interventions constituted a violation of its own policies and regulatory requirements regarding the response to alleged abuse.