Failure to Investigate Allegations of Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to thoroughly investigate incidents involving allegations of inappropriate sexual behavior, specifically public urination by a resident in the presence of others. One resident, who was cognitively intact and required some assistance with mobility and toileting, was reported to have urinated in the courtyard in front of other residents and guests. Although a nurse documented that there were no complaints from residents present at the time, there was no documentation of which residents were interviewed or whether residents who may have witnessed the incident from inside the building were questioned. The facility Administrator confirmed that no incident or police report was filed for this event, and there was no documentation of a comprehensive investigation. A subsequent incident involved the same resident urinating in the courtyard, which led to another resident filing a police report, citing frustration with repeated occurrences. The Social Services Supervisor communicated the incident to the Administrator and DON via email, noting that two residents were upset, especially as one had visiting grandchildren. Despite this, there was no documented evidence of a formal investigation into the allegations or the residents' concerns. The facility's Abuse Prohibition Policy requires that all allegations of abuse, including sexual abuse and mistreatment, be reported, investigated, and documented, but these procedures were not followed in these cases.