Failure to Fully Investigate Resident’s Sexual Abuse Allegation Against Staff
Penalty
Summary
Facility staff failed to complete and document a full investigation of an allegation of sexual abuse made by one cognitively intact resident against a restorative nurse aide (RNA). The resident, who had diagnoses including metabolic encephalopathy, schizophrenia, generalized anxiety disorder, impulse disorder, restlessness, agitation, and a documented history of cussing, yelling, agitation with staff and other residents, lying about staff behavior, and using manipulative tactics, reported to the DON that the RNA had been making the resident "suck his/her boob and play with him/her" and stated this had been occurring "for a while." The resident’s care plan also noted physical and verbal behavioral symptoms directed toward others and other behavioral symptoms. Despite this behavioral history, the allegation itself was clearly documented by the DON in a progress note. The facility’s abuse policy stated that each resident will be free from abuse, that all employees alleged to have committed abuse will be suspended immediately pending investigation, and that the facility will complete an investigation. In this case, the DON interviewed the resident and the accused RNA in the presence of a CMT as a witness. The resident repeated the allegation quietly with head down, and the RNA denied any inappropriate conduct, stating the resident had urinated on the floor, was told to change clothes, became angry, and threatened to get the RNA fired. The DON decided not to send the RNA home and instead instructed the RNA and resident to have no contact. No additional staff or residents were interviewed, and there was no documented, complete, and timely investigation of the allegation as required by policy. Multiple staff interviews confirmed that a staff member asking a resident to suck their breast or play with them would be considered sexual abuse and should be reported and investigated, with the accused staff typically suspended pending investigation. CNAs, RNs, the SSD, and the Administrator all characterized such conduct as sexual abuse and described that the usual process would include suspending the accused staff and conducting an investigation. The SSD reported that the DON told him about the allegation and that the RNA continued to work and was not suspended. The Administrator stated he was not informed that the resident had actually made the sexual abuse allegation, and when the DON’s note was read to him, he agreed it should have been reported as sexual abuse. Review of state records showed the facility did not provide a documented, complete, and timely investigation of the allegation of abuse, and the DON acknowledged not completing a full investigation beyond interviewing only the resident and the RNA.
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