Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged sexual abuse incident involving a resident with dementia, type II diabetes mellitus, and bipolar disorder. The resident was admitted to the emergency room after EMS was called for a hyperglycemic event, during which the resident reported to EMS that his roommate had fondled him in the bathroom. The ER records indicated that the resident was visibly distressed, and the facility Director acknowledged that similar allegations had previously been made against the same roommate, with a police report already filed. Despite these circumstances, the facility did not initiate or document a Self-Reported Incident (SRI) for this allegation. A review of facility records confirmed that no investigation was conducted regarding the reported sexual abuse. The Administrator verified that there was no documentation or evidence of an investigation into the incident. Facility policy requires immediate initiation of an investigation into any abuse allegations, including a root cause analysis and cooperation from all staff to ensure resident protection. However, these procedures were not followed in this case, resulting in non-compliance with the facility's abuse investigation policy.