F0610

D

Delayed and Incomplete Investigation of Alleged Resident-to-Resident Sexual Abuse

Denver, Colorado Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency centers on the facility’s failure to promptly and thoroughly investigate an allegation of sexual abuse between two residents with severe cognitive impairment, and to adequately document resident monitoring and behaviors surrounding the event. On the evening in question, a CNA heard one resident yelling from her room and entered to find a male resident standing over her bed with his hands on her chest and abdomen area, over her clothing and bedding. Initially, the CNA reported uncertainty about whether the male resident had actually touched the female resident, later clarifying that he had placed his hands on her chest and abdomen. Despite this, the facility did not immediately initiate an abuse investigation at the time of the incident, and the event was not initially considered sexual abuse.

The investigation and documentation were delayed and incomplete. The alleged victim was not interviewed until approximately 12 hours after the incident, at which time she did not remember anyone coming into her room or touching her. The alleged perpetrator was not interviewed until about 14 hours after the incident and similarly did not recall entering another resident’s room or hearing anyone calling for help. Both residents had severely impaired cognition, and the delay meant they were unable to provide details of the incident. The facility’s review of hallway video surveillance documented the male resident entering and exiting the female resident’s room and the CNA’s response, but did not establish the exact time he entered the room or how long he remained there before staff intervened.

The facility’s investigation also lacked sufficient detail in witness statements and failed to fully explore key information. The CNA’s written statement did not describe the type of touch, the demeanor of either resident, or what the yelling resident was saying. There was no explanation documented for the change in the CNA’s account from the resident’s hands “hovering” to actually touching the other resident. Another resident in a nearby room reported hearing the female resident yelling for help in Spanish for about 10–20 minutes before staff responded, and later overheard staff discussing that a male resident had been in her room touching and groping her; however, this level of detail was not captured in the initial witness statement or incorporated into the investigation. Additionally, there was no documented effort to determine the root cause of the yelling, no documentation of staff monitoring or interventions for the yelling on the evening of the incident, and no timely examination of the alleged victim for injuries that night.

Record review further showed that the yelling resident had documented distressing behaviors the day before, including calling out for help, becoming upset when staff attempted to assist, and pinching staff, with a physician notified and new orders initiated. However, there was no documentation of continued behavior monitoring or of her calling out for help on the evening of the alleged abuse, nor of staff actions to monitor and intervene at that time. Staff interviews revealed inconsistent understanding of reporting and investigation expectations, with one CNA stating that after breaking up a resident-to-resident abuse situation and notifying nursing, there was “nothing else to report.” Administrative staff could not demonstrate that the investigator obtained detailed information from the CNA about the exact location and nature of the touching or what the yelling resident was saying, and there was no documentation that later assessments or theories about the male resident’s intent were incorporated into the formal investigation. These omissions and delays in investigation, interviewing, and documentation constitute the core of the cited deficiency.