Failure to Thoroughly Investigate Resident-to-Resident Sexual Incident
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation following a resident-to-resident sexual incident. Resident #1, admitted in December 2014 with vascular dementia, schizophrenia, and anxiety disorder, had severely impaired cognition (BIMS score of 4), was dependent for personal hygiene, toileting, and bathing, and used a wheelchair. Resident #1’s care plan identified a history of engaging in non-consensual sexual advances by others, with interventions including close observation as indicated per policy. Resident #2, admitted in July 2008 with vascular dementia, schizophrenia, and anxiety disorder, also had severely impaired cognition (BIMS score of 6), required set-up/clean-up assistance for personal and oral hygiene and toileting, and ambulated independently. Resident #2’s care plan noted dementia-related memory and thinking problems, with interventions to avoid correcting the resident’s believed statements and to provide simple responses. On the date of the incident, a Recreation Assistant observed Resident #1 and Resident #2 kissing in an elevator, with Resident #2’s hands in Resident #1’s pants, and this was documented on a Reportable Event Form by the DNS. The facility’s investigation included interviews with the witness (Recreation Assistant) and both residents, but did not include interviews or statements from other staff to determine how long the residents had been unsupervised or their locations prior to the incident. Subsequent interviews with a NA assigned to Resident #2 and an LPN assigned to Resident #1 revealed each had last seen their assigned resident around early afternoon, but these interviews were not part of the original investigation. The DNS acknowledged that the investigation should have included staff interviews to establish a timeline and resident whereabouts, as required by the facility’s “Reportable Events-Reporting Allegations and Incidents; Investigation (CT)” policy, which directs identifying and interviewing staff who were potential witnesses and reviewing work schedules, with efforts to interview staff before the end of their shifts.
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