Failure to Thoroughly Investigate and Prevent Further Abuse Following Allegation
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that steps were taken to prevent further abuse for one resident. Upon learning of an allegation of sexual misconduct involving a certified nursing assistant (CNA) and a resident, the facility did not provide evidence that all necessary protective measures were implemented for the affected resident and other residents. The facility's own policy requires immediate protection of the resident, removal from harm, and a thorough investigation, including interviewing all potentially affected residents and relevant staff, as well as documentation of staff education and timely reporting to authorities. The incident involved a resident with severe anemia, major depressive disorder, and anxiety disorder, who was cognitively intact at the time of the event. The allegation was based on a staff report of a rumor regarding potential sexual misconduct by a CNA during a resident's bath. The facility removed the accused CNA from the schedule and interviewed two male residents who could communicate and had received whirlpools from the accused CNA. However, the investigation did not include interviews with all residents or staff from different shifts, and there was no documentation of staff education on abuse reporting. Additionally, the facility did not conduct a comprehensive skin assessment of all residents after the allegation was reported. Interviews with facility leadership confirmed that only staff with direct knowledge of the incident were interviewed, and education on abuse reporting was provided verbally but not documented. The facility did not interview all residents or staff, nor did it complete a house-wide skin assessment following the allegation. The investigation was limited in scope, and the facility failed to provide evidence that all steps were taken to prevent further abuse or to ensure a thorough investigation as required by policy.