Failure to Thoroughly Investigate Resident’s Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse reported by a resident. A facility-reported incident indicated that a resident told a staff member on one date that he/she was uncomfortable with the way another staff member had cared for him/her several days earlier, and the initial report to the state agency categorized the allegation as physical. The facility’s investigation lacked a statement from the staff member who first received the report, including what was reported and when. The resident’s own statement was not obtained until the following day, and when it was documented by the Social Services Assistant, the resident reported seeing the staff member’s fingers in his/her private area. Further review of the resident’s medical record showed that a Psychiatric Mental Health NP documented that the resident reported the allegation to the Dietitian on the same day the incident was reported to the state, but the facility’s investigation contained no statement from the Dietitian. The investigation provided to the surveyor also did not include emergency room documentation. Only after surveyor intervention was the ER record produced, which contained the resident’s chief complaint in his/her own words that he/she had been sexually assaulted by a male staff member on a prior Saturday evening. The Facility Reported Incident Follow-Up Investigation Report submitted by the Administrator did not include the resident’s statement alleging sexual abuse, and the Corporate Nurse confirmed that the investigation did not include necessary interviews, ER documentation, or a complete investigation of the allegation.
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