Failure to Thoroughly Investigate Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of sexual abuse involving Resident #77. Resident #77 was admitted with dementia with psychotic disturbance, cognitive communication deficit, and type 2 diabetes, and had a care plan identifying impaired cognitive function and the need for supervision, reorientation, and monitoring for changes. A 5-Day MDS assessment documented severe cognitive impairment, and an attempted interview during the survey showed the resident could only state her name and was unable to answer questions. Despite these documented cognitive limitations, there were no progress notes in the medical record addressing the alleged physical or sexual abuse on the date of the incident. The alleged perpetrator, Resident #43, had diagnoses including cerebral infarction, schizophrenia, and psychoactive substance abuse, and was documented as cognitively intact and ambulatory on the admission MDS. The care plan for Resident #43 did not include any information related to sexual history or sexual behaviors. According to the facility’s self-reported incident (SRI), a CNA witnessed Resident #43 lift Resident #77’s shirt and touch her left breast at approximately 10:30 P.M., then immediately separated the residents and reported the incident to an LPN, who notified the DON. The SRI indicated an investigation was started, including monitoring both residents, and the facility ultimately concluded that no abuse had occurred. However, the investigation did not include interviewing all relevant witnesses as required by the facility’s abuse policy. LPN #267, who was working and orienting with the reporting LPN at the time of the incident and who heard the CNA’s report that Resident #43 went into Resident #77’s shirt and rubbed her breast, was never interviewed or asked to provide a statement. The Administrator acknowledged he did not interview LPN #267 and was unaware of the CNA’s written witness statement describing breast touching, and he stated the allegation was found unsubstantiated because it was reported that the resident lifted her own shirt and there were no witnesses. Additionally, Resident #77’s husband reported that the incident was downplayed to him by the Administrator and that he was not informed that his wife’s breast had been touched inappropriately. The facility’s policy required interviewing all witnesses, but this was not done, resulting in an incomplete investigation of the sexual abuse allegation.
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