F0610

D

Failure to Thoroughly Investigate Alleged Staff-to-Resident Sexual Misconduct

Los Angeles, California Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of staff-to-resident sexual misconduct involving Resident 4. Resident 4, who had COPD and type 2 diabetes mellitus, was assessed on a recent MDS as having some difficulty with daily decision making in new situations but without inattention, disorganized thinking, or altered level of consciousness. Resident 4 reported that during nighttime hours, on the night before her most recent hospitalization, a tall male staff member of African descent with dark skin and an accent exposed his genitals, placed his penis on her hand, and then engaged in unprotected sexual intercourse with her in her bed. Resident 4 stated she reported this alleged encounter to staff upon her return from the hospital and identified the ADON as the first person she informed.

The ADON acknowledged that Resident 4 reported the alleged sexual encounter and provided a description of the alleged perpetrator as tall, of African descent, with dark skin and an accent. The ADON stated she attempted to identify the alleged perpetrator by recalling male staff characteristics from memory and concluded that no one matched the description, without using staffing records or other objective data. The DSS similarly stated that Resident 4 described the alleged perpetrator as an African male and that there were no male staff who matched this description. The AADM, who was responsible for the investigation, reported that he interviewed Resident 4 and one CNA (CNA 3), whom he felt matched the description, but he did not take into account Resident 4’s report of the date and time of the incident to identify other potential staff. The DSD, who was supposed to conduct additional staff interviews, stated that as of several days after the allegation was reported, she had not interviewed any male staff matching the resident’s description who were working on or around the date of the alleged incident.

The AADM submitted a conclusion letter to the State Agency indicating that the investigation was complete, that the alleged incident occurred on a date that did not correctly correspond to the resident’s hospitalization, and that no staff matched the resident’s description or had knowledge of the incident. The AADM later acknowledged that the incident date in the letter was incorrect and that he had assumed the alleged perpetrator had been terminated based solely on the resident’s statement that she had not seen the staff member since the incident, without confirming this through records. He also acknowledged that he did not verify that the DSD had completed staff interviews and that there were no documented interviews to demonstrate that an investigation had been conducted, despite the conclusion letter stating that interviews with current and former male staff had been done. Staffing assignments for the relevant night shifts showed multiple male staff, including those assigned to the resident’s care, but there was no documentation that these individuals were interviewed. Facility policies required prompt, thorough, and documented investigations of abuse allegations, including interviewing individuals who may have relevant information and suspending accused staff, but the investigation into Resident 4’s allegation was incomplete and not thoroughly documented as required.

The facility’s own Follow-Up Investigation Report stated that a payroll report of all male staff was generated and that only one person fit the description, but the report did not specify what actions were taken regarding that staff member. The same report’s sections on interviews with alleged perpetrators and the conclusion stated that no one had any knowledge of the incident and that no one fit the description, despite the AADM’s admission that he had not confirmed that interviews were completed and could not provide documentation of such interviews. Additionally, the facility’s policies on Protection of Resident, Abuse – Reporting and Investigations, and Abuse and Neglect Prohibition Policy required that investigations be initiated within 24 hours, that they be thoroughly documented on the facility’s investigation form, and that involved or accused staff be placed on investigative leave or suspended until the investigation results were reviewed by the Administrator. These policy requirements were not met in the handling of Resident 4’s allegation, resulting in a deficient practice related to the facility’s response to alleged staff-to-resident sexual misconduct.