F0600

D

Incomplete Investigation of Alleged Resident-to-Resident Sexual Abuse

Spring House, Pennsylvania Survey Completed on 04-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct a complete and thorough investigation of an allegation of resident-to-resident sexual abuse involving one resident (R1) out of three reviewed. Facility policy titled “Abuse Investigating and Reporting” (revised 2016) required the Administrator to assign investigations appropriately and ensure prevention of further potential abuse, neglect, exploitation, or mistreatment when an incident or suspected incident is reported. R1 had diagnoses including dysphagia, aphasia, dementia, and cerebral infarction, and was documented as cognitively impaired on the January 2, 2026 MDS. Another resident, R2, had multiple diagnoses including diabetes, seizures, chronic kidney disease, schizoaffective disorder, and frontotemporal neurocognitive disorder, and was documented as awake, alert, and oriented on the February 19, 2026 MDS.

On the date of the incident, documentation submitted to the State Survey Agency indicated that a resident (R3) reported that R1 was inappropriately touched in the dining room by R2. An incident report completed by a nurse (E3) stated that an activity worker (E4) reported R2 inappropriately touching R1 in the first-floor dining room and that both residents were immediately separated, with R1 taken back to her second-floor bedroom. E3 was not present for the incident and completed an incident report based on what she was told when she started her shift. E3 performed a full body assessment on R1 and found no bruises or injuries. A statement by activity staff (E4) documented that he witnessed R2 caressing R1’s inner thigh before removing him from the dining room, and a second undated statement from E4 indicated that R3 told him he had witnessed R2 assaulting R1 and that R1 was being groped.

In an interview, E4 reported that R1 and R2 were seated near the back wall of the first-floor dining room, with two activity workers present and about 50 residents in the room. E4 stated that R3 called him and told him to remove R2 because R3 saw R2 touching R1 inappropriately, including feeling R1’s thighs and breast and putting his hands in her pants. E4 reported taking R2 to the nursing station and informing a nurse whose name he could not recall, then later observing R2 back in the activity room near R1 with his hand on her inner thigh close to her vagina, after which he again took R2 to the nursing station. A separate incident report by another nurse (E5) documented that R2 had been observed by another resident earlier, was placed at the nursing station for supervision, and later was seen kissing the same female resident (R1) in the same dining room. E5 stated she was told by the activity aide that R2 was witnessed touching and kissing R1 and that R2 returned to the dining room and was again involved in an incident of kissing R1.

A nursing note by the 3–11 p.m. nursing supervisor (E6) documented that she was notified by a male staff member that R2 was seen inappropriately touching R1 and that R2 was placed on 1:1 supervision, with the physician notified and an order obtained to send R2 to the emergency room for evaluation. In an interview, E6 reported she was completing an admission when notified that R2 was observed touching R1’s breast area and that, by the time she left her office, the residents had already been separated and R2 placed on 1:1 supervision. The facility’s investigation ultimately unsubstantiated the allegation of resident-to-resident abuse for inappropriate touching, noting that E4 reported seeing R2 caressing R1’s inner thigh while she was wearing blue pants and that he was touching the outside of the pants.

Surveyor review of the investigation found that it lacked key elements required for a complete and thorough inquiry. The investigation did not include any statements from residents who were present in the dining room during the alleged incidents. There was no dated, signed interview statement from R3, who initially reported the inappropriate touching. The investigation also did not contain any statement from the second activity worker (E7) who was present in the dining room and giving out snacks at the time of the events, nor any witness statement from R2 regarding the various accounts of his behavior. During interviews with the DON, the Nursing Home Administrator, and the Regional NHA, it was acknowledged that there were no resident witness statements from those present in the dining room, no statement from R3, and no statement from E7 about what he may or may not have witnessed. This incomplete documentation and failure to obtain and include all relevant witness accounts formed the basis of the cited deficiency for failure to conduct a complete and thorough abuse investigation.

Plan Of Correction

Plan of Correction:

The facility immediately assessed Resident R1 with no injuries noted. Resident R2 was immediately separated, placed on 1:1 supervision, sent to the hospital for evaluation, and remained on 1:1 supervision until cleared by psychiatry. The provider and responsible party were notified and the incident was reported to the Department of Health. The facility conducted an investigation and interviewed all available witnesses during the investigation. All residents have the potential to be affected by this deficient practice.

An abuse and neglect checklist tool will be implemented to ensure all allegations are thoroughly investigated, including obtaining statements from all available witnesses. Education will be provided to staff on abuse/neglect reporting and investigation requirements, including immediate protection of residents and obtaining required witness statements. Administrator or designee will review all abuse investigations for completeness and required documentation. Audits will be conducted weekly x4 weeks, then monthly x3 months. Findings will be reported to the QAPI committee.