Failure to Thoroughly Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse made by a resident and did not report the results of the investigation to the state survey agency within five working days, as required. The incident involved a female resident with a history of trauma, major depressive disorder, borderline personality disorder, and unspecified psychosis, who reported that a tall black man entered her room during the night and touched her vaginal area. The resident had a BIMS score indicating no cognitive impairment and was her own responsible party. Upon being informed of the allegation, the DON instructed a staff nurse to perform a complete skin survey and suspended the aide assigned to the resident's hall pending investigation. Statements were collected from staff, and the incident was reported to the state agency (HHSC), but there was no evidence that law enforcement was notified or that the resident was offered the opportunity to speak with police. Interviews and record reviews revealed inconsistencies in the investigation process. The resident described the incident in detail to multiple staff members, including the DON, RN, NP, and social worker, and expressed that she wanted to make a police report but was not given the opportunity. Staff assessments found no physical evidence of injury or penetration, and the resident later clarified that she was sexually molested, not raped. The staff involved in the investigation, including the DON and Administrator, indicated that they did not notify law enforcement because the resident did not explicitly request it or because they did not believe the allegation due to the resident's history of making false accusations. The facility's policy required immediate reporting of abuse allegations to law enforcement, but this step was omitted. The investigation documentation showed that safety checks were performed on other residents in the hall, and the accused staff member was suspended. However, the facility did not provide evidence that all alleged violations were thoroughly investigated or that the results were reported to the state survey agency within the required timeframe. The Administrator acknowledged that he was unaware of the requirement to notify law enforcement and deferred the investigation to the DON in his absence. The lack of a thorough investigation and failure to notify law enforcement constituted a deficiency in the facility's response to the abuse allegation.