Failure to Thoroughly Investigate Alleged Sexual Abuse and Potential Additional Victims
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving one resident and did not determine the extent of potential abuse among other residents cared for by the same staff member. Facility policies on Abuse Protection and Abuse Reporting and Investigation, reviewed on 9/3/25, state that all residents have the right to be free from abuse and that the facility will conduct a thorough investigation of all abuse reports, including providing psychosocial support and protecting the resident during the investigation. The Nursing Home Administrator reported that an investigation had been conducted into an allegation of sexual abuse involving Resident R1 and Nurse Aide Employee E1, and the facility’s investigation concluded that the allegation was unfounded. However, the investigation did not include interviews with any of the other 12 residents who had been cared for by the same nurse aide on the night in question to identify possible additional victims. Resident R1 reported that the nurse aide entered her room to change her after an incontinent episode of urine, removed the front of her brief, wiped the sides of her front without cleaning her, then turned her onto her side, removed the brief, and pressed on her hemorrhoid in and out several times without using a rag or wipe. Resident R1 stated she did not have a bowel movement, that she was not cleaned, and that the aide simply applied a new brief and left. Resident R1 reported that she asked the aide to have the nurse come in and told the nurse she felt violated and later stated she felt assaulted, noting that this had never happened before and that she now feels safe because the aide no longer works there. The Nursing Home Administrator confirmed that the allegation was classified as unsubstantiated and acknowledged that no interviews were conducted with the other 12 residents cared for by the aide during that shift, and that the incident was not thoroughly investigated and resident statements regarding their care on the night shift were not obtained.
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