Failure to Thoroughly Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of resident-to-resident sexual abuse involving two sampled residents. A male resident with a disability, cognitively able to make himself understood, reported that a female resident with a history of mental and behavioral disorders approached him in the activity room, licked her lips, stuck out her tongue, rubbed his thighs without consent, grabbed his genitals, and made sexual comments, leaving him feeling embarrassed, angry, and unsafe. The facility did not become aware of this allegation until notified by the Ombudsman, and the subsequent investigation, documented as a five-day report, concluded the allegations could not be proven factual after only interviewing the Activity Director, who reported never having seen such behavior. The Administrator later acknowledged he did not conduct that investigation and that it was not done thoroughly, including that additional resident interviews were not completed and the investigation was not re-done once this was realized. Additional interviews and observations during the survey revealed that the alleged perpetrating resident had a BIMS score of 7/15, indicating cognitive impairment, and refused to participate in the investigation. Another male resident reported that this same female resident had tried to touch and grab his genitals, making him upset and angry, and a third male resident recalled her grabbing his buttocks and described feeling startled and uncomfortable around her. The DON stated he was aware that this resident exhibited hyper-sexualized behaviors toward male staff and residents, including grabbing his buttocks and making explicit sexual comments, and that he had witnessed her touching residents inappropriately but could not identify which residents. Despite the facility’s written abuse prevention and management policy requiring immediate reporting, initiation of an investigation, and interviews with all individuals who may have relevant information, including residents and witnesses, the investigation into the allegation between the two sampled residents did not include these required steps and was not comprehensive.
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