Failure to Thoroughly Investigate Alleged Sexual Abuse Between Residents
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a cognitively intact resident with known sexually inappropriate behaviors and a severely cognitively impaired resident. The alleged perpetrator had dementia, a history of traumatic brain injury, and a care plan identifying sexually inappropriate behavior, with interventions such as removal from situations and explanation of inappropriate behavior. On the date of the incident, a staff member reported to the NP that this resident had his hands inside the back of another resident’s pants and that both residents were kissing. The NP documented that the resident was a registered sex offender and had a history of making sexually explicit comments in common areas and becoming upset when redirected. A later NP note, based on information from the DON after review of camera footage, stated that the initial report was inaccurate and that the residents were holding hands, with one instance of the alleged perpetrator placing his hand on the alleged victim’s thigh. The alleged victim was a resident with schizoaffective disorder, dementia, bipolar disorder, obsessive compulsive behavior, anxiety disorder, and Alzheimer’s disease, with a care plan noting impaired cognition, hearing deficit, and neurocognitive disorder. The resident’s MDS showed a BIMS score of 0, indicating severe cognitive impairment, and interventions included anticipating needs, maintaining consistent routines, and facilitating communication. Despite the reported incident between these two residents, there was no documentation in the alleged victim’s clinical record of the event on the date it was reported. The facility’s records contained no evidence that a formal incident report or a comprehensive investigation specific to this allegation was completed or documented. Interviews with the ADON, DON, Administrator, and other staff further demonstrated that the allegation was not thoroughly investigated in accordance with facility policy. The ADON and DON acknowledged awareness of a report that the resident placed his hands down a female resident’s pants but could not identify who reported it, and neither could identify the female resident involved, despite the DON and Administrator stating they had reviewed video footage. The DON stated the incident was considered a behavior and not abuse and therefore was not reported to the State Agency, and he indicated that an investigation was not needed because the incident occurred on the behavior unit. The NP confirmed he did not witness the incident or review the video and wrote a second note based on the DON’s description. Review of the facility’s abuse policy showed that all allegations of abuse must be thoroughly investigated and reported, including review of records, interviews with reporters, witnesses, the resident, and others, and complete documentation of findings, which was not evidenced in this case, nor was there evidence that the results of any investigation were reported to the State Agency within 5 working days.
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