Failure to Protect Residents from Abuse Due to Incomplete Investigation
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, as evidenced by its handling of three separate allegations involving two residents. Both residents had significant care needs, including frequent incontinence and assistance with daily hygiene, grooming, and dressing. One resident reported to a Certified Occupational Therapy Assistant (COTA) that an employee, while assisting with incontinence care, touched her inappropriately and that she did not want him to assist her further. The other resident reported that the same employee opened her house dress without reason, looked at her, and ran his hand up and down her body, causing her fear. Additionally, the first resident reported that the employee pushed and shoved the second resident during a transfer to bed. All incidents were reported to a supervisor immediately by the COTA. Despite these reports, the facility did not recognize the allegations as sexual and physical abuse and failed to initiate or complete investigations into the incidents before allowing the accused employee to return to work. The employee was initially suspended but was brought back to work after receiving education, without the completion of the required investigations. It was only after several days that the facility realized not all allegations had been investigated, leading to the employee's suspension again. This failure to follow policy and ensure a thorough investigation before allowing the employee to have resident contact resulted in the facility not protecting residents from potential abuse.