Failure to Investigate and Protect Resident After Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely investigate and document an allegation of abuse and to document steps taken to protect a resident following that allegation. Facility policy on Abuse Investigation and Reporting required that all reports of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown origin be promptly reported and thoroughly investigated, with the Administrator assigning an investigator and the investigation including review of documentation, medical records, and interviews with the reporter, resident, witnesses, staff, and others. The policy also required private interviews and written, signed, and dated witness statements. Despite these requirements, when a resident with paranoid schizophrenia, moderate cognitive impairment, delusions, and verbal behavioral symptoms alleged that another resident was putting his penis in the resident’s buttocks, the responsible LPN only documented the allegation and a brief interaction with the resident, without initiating or documenting any investigative steps or protective measures. The resident’s progress note described the resident yelling and making a specific sexual abuse allegation, including a hand gesture indicating penetration, and the LPN’s response that the alleged perpetrator was asleep and that the act was impossible, along with a statement that racial slurs and name calling were not tolerated. There was no documentation of a physical assessment, notifications, or further follow-up related to the sexual abuse allegation in the electronic medical record. The LPN later stated that no assessment was completed, that the allegation was reported only in shift report, and that the resident would have been moved and monitored if the LPN had believed the allegation was credible. The Administrator and ADON reported that they were unaware of the allegation, that an assessment and investigation with staff and resident interviews and chart review should have occurred, and that investigations should be completed within five days, but no investigation report had been submitted to the state agency as of the surveyor’s review date.
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