F0607

D

Failure to Report and Investigate Alleged Sexual Abuse Between Residents

Lakeside, Arizona Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its abuse, neglect, exploitation, and misappropriation reporting and investigation policy after an allegation of sexual abuse between two residents. One resident, identified as having dementia, a history of traumatic brain injury, anxiety disorder, major depressive disorder, transient ischemic attack, and cerebral infarction, was care planned for behavior problems including wandering, refusing care, eating other residents’ food, and being sexually inappropriate. A Nurse Practitioner (NP) note documented that staff reported this resident had his hands inside the back of another resident’s pants while both residents were kissing, and that this resident was a registered sex offender with a history of making sexually explicit comments in common areas and becoming upset when redirected. The facility’s policy required immediate reporting of suspected abuse to the administrator and state and local agencies, and a thorough investigation, but this did not occur as required.

The alleged victim was a resident with schizoaffective disorder, dementia, bipolar disorder, obsessive compulsive behavior, anxiety disorder, and Alzheimer’s disease, who had severe cognitive impairment as evidenced by a BIMS score of 00. This resident’s care plan identified communication problems related to impaired cognition and hearing deficit, and interventions such as anticipating needs, maintaining consistent routines, and using strategies to reduce confusion. Despite the NP note describing staff reports that the alleged perpetrator had his hands down this resident’s pants and that both residents were kissing, there was no documentation in the alleged victim’s clinical record of an incident with another resident on the date in question. There was also no documentation that the incident was reported to the State Agency, Ombudsman, or law enforcement, and no evidence that a thorough investigation was completed and reported within 5 working days as required by facility policy.

Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), Administrator, and other staff further demonstrated that the facility did not implement its abuse reporting and investigation policy. The ADON acknowledged awareness of a report that the alleged perpetrator put his hands down a female resident’s pants and stated it was reported to the DON and Administrator, but she did not know who witnessed the incident and did not review the camera footage. The DON and Administrator stated they reviewed video footage and concluded the residents were holding hands and that on one occasion the alleged perpetrator placed his hand on the alleged victim’s thigh; they considered the event a behavior rather than abuse and did not report it to the State Agency. They also stated they did not know the identity of the female resident involved, and the video footage was no longer available due to automatic deletion after 72 hours. The DON stated it would only be considered abuse if the psychiatric provider said so and that no preventive measures were in place because the sexually inappropriate conduct was considered a behavior. The NP reported he did not witness the incident or review the footage and wrote a second note after the DON described what he saw on the video. Other staff reported hearing about the incident but did not witness it. These actions and omissions show the facility did not follow its own policy requiring immediate reporting, preservation of evidence, identification and interview of involved parties and witnesses, and complete documentation of the investigation.

The facility’s written policy on Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating required that all reports of resident abuse, including suspected abuse and injuries of unknown origin, be immediately reported to the administrator and to state and local agencies, including the state licensing/certification agency, Ombudsman, adult protective services (where applicable), and law enforcement. The policy also required that the administrator initiate and ensure a thorough investigation, including review of documentation and evidence, review of the resident’s medical record and condition, observation of the alleged victim, interviews with the reporter, witnesses, the resident or representative, physician as needed, staff on all shifts, roommates, family, visitors, and other residents cared for by the accused, as well as complete documentation of the investigation. In this case, there was no evidence that these required steps were carried out, that the alleged victim was assessed or interviewed as appropriate, that witnesses were identified and interviewed, or that evidence such as video footage was preserved and protected from destruction. The failure to follow these policy requirements in response to the allegation of sexual abuse between residents constitutes the cited deficiency.