Failure to Investigate Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving one cognitively impaired female resident and one cognitively impaired male resident. The female resident had severe cognitive impairment and diagnoses including cerebral infarction, bipolar disorder, memory deficit, TIA, depression, left-sided paralysis, and a history of falls and psychosocial well-being problems. The male resident also had severe cognitive impairment and diagnoses including vascular dementia with mood disturbance, depression, cerebral infarction, and cognitive communication deficit, and was care planned for risks related to altered neurological status, depression, and impaired cognitive function. The Administrator, who served as the abuse coordinator, reported being informed by an unidentified staff member that the male resident touched the female resident in her private area while they were in the dining area. He stated that the residents were separated, the male resident was placed on 1:1 monitoring, and then discharged and transferred to another facility the following day. Despite the Administrator’s statement that he completed an investigation, there was no documentation of any abuse investigation or 1:1 monitoring in either resident’s EMR. The DON indicated that the Administrator should have a copy of the investigation, but none was available in the records reviewed. The corporate Administrator later confirmed that an investigation had not been completed and that work on an investigation would begin at that time. Review of the facility’s abuse policy showed that all allegations of abuse were to be promptly and thoroughly investigated by the Administrator or designee, that a licensed nurse was to immediately examine the resident and document findings in the medical record, and that all identified events were to be reported to the Administrator immediately. Record review and interviews showed that these required investigative steps and documentation were not carried out for the alleged sexual abuse incident involving these two residents.
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