Failure to Thoroughly Investigate Sexual Abuse Allegation and Protect Residents from Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff-to-resident sexual abuse and to protect residents after the allegation. A cognitively impaired resident with severe dementia, depression, and a history of occasional delusional thinking reported that a male staff member attempted to put his "thing" in her mouth, gesturing toward her own and the nurse’s private areas. The resident identified the alleged perpetrator by name and described his clothing, which matched that of a male CNA on duty. The resident appeared upset and was yelling when initially interviewed by the social worker designee and human resources director, and later became guarded and defensive when asked by surveyors about the incident, stating she had been told she was safe and that the man would no longer care for her, and that she was told not to discuss the incident. Staff actions and documentation on the date of the allegation were incomplete and did not meet the facility’s own abuse policy. The LPN caring for the resident was informed by the CNA that the resident was combative during care and, upon assessing the resident, heard the resident’s statements about the attempted sexual act. The LPN reported the concern to the social worker designee because administration was not yet on site. The social worker designee and human resources director interviewed the resident, confirmed the description of the CNA’s clothing, and notified the Administrator by phone. The Administrator, via speaker phone, directed that the CNA leave the facility pending investigation, and the CNA clocked out that morning. However, the facility’s internal investigation file for that date contained only brief, non-witness statements from other staff attesting that they had never seen the CNA be abusive, and lacked detailed statements from the social worker designee, human resources director, the LPN who received the allegation, or the CNA accused. There was no documentation in the medical record regarding the resident’s allegation or the events of that day. The facility’s investigation summary for the date of the allegation concluded that the resident was confused and combative during personal care and that no abuse occurred, relying in part on the resident’s son’s statement that the resident behaves that way when she has a UTI and that he did not think an investigation was warranted. The assistant DON confirmed that no deeper investigation was conducted and that the incident was not reported to the state agency, despite facility policy requiring reporting of any allegations or suspicions of abuse prior to investigation. Furthermore, after being sent home the day of the allegation, the CNA was allowed to return to work on the next scheduled shift and was assigned as a shower aide on a different unit, providing care to eight other residents while the initial allegation had not been fully investigated or reported. The DON and ADON verified that the CNA worked that full shift with resident care responsibilities before being placed on leave when a formal allegation was later made by the resident’s son.
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