Failure to Investigate Allegation of Sexual Abuse After Resident Discharge
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving one of four sampled residents. The resident was admitted with diagnoses including acute respiratory failure, diabetes mellitus, and hypertension. According to the resident’s AMA (against medical advice) Release Form, the resident left the facility against medical advice on February 17, 2026. During a telephone interview on February 23, 2026, the resident’s family member reported that during an out-on-pass on February 15, 2026, the resident alleged she had been sexually abused by a staff member at the facility. The family member stated he reported the allegation to the sheriff’s and police departments and then took the resident home after discharging her AMA on February 17, 2026. In a subsequent interview, the DON stated that law enforcement came to the facility in response to the resident’s allegation of abuse. The DON acknowledged that the facility did not initiate an internal investigation or report the allegation to the California Department of Public Health because the resident had already been discharged when the facility became aware of the allegation. During a later record review, the DON reviewed and acknowledged the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, which requires the facility to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property, and to investigate and report any allegations within timeframes required by federal requirements.
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