Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 4
Sep 21, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint intakes #GA00217495, #GA00217477, and #GA00217497.
Findings
The facility failed to ensure the safety and rights of Resident #1 by not preventing sexual abuse by Staff D, who was witnessed sexually assaulting the resident. The incident was not reported immediately to the police or the Department, resulting in delayed notification and investigation. Staff failed to follow abuse reporting policies, and the administrator did not initiate an immediate investigation or report to the resident's representative in a timely manner.
Complaint Details
The investigation was triggered by complaint intakes #GA00217495, #GA00217477, and #GA00217497 regarding a sexual assault incident involving Resident #1 on 9/5/21. The incident was witnessed by Staff C but was not reported to police or the Department until 9/8/21. Staff D was arrested for felony charges of abuse and sexual assault. The facility failed to report and investigate the incident promptly, violating abuse reporting requirements.
Severity Breakdown
D: 2
J: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement policies and procedures supporting residents in a safe environment, resulting in sexual assault of Resident #1 by Staff D. | D |
| Failure to ensure residents' rights to be free from sexual abuse for Resident #1. | J |
| Failure to initiate immediate investigation and report to resident's representative following sexual assault incident. | J |
| Failure to report serious incident of sexual assault to the Department in a timely manner. | D |
Report Facts
Residents observed in MCU during tour: 16
Days delay in reporting incident: 3
Felony charges against Staff D: 2
Resident #1 admission date: Jan 20, 2021
Resident #1 hospital discharge days after incident: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Witnessed the sexual assault of Resident #1 and reported the incident to Staff E but did not report to police or Department immediately. | |
| Staff D | Perpetrator of sexual assault against Resident #1; arrested for two felony charges. | |
| Staff A | Returned from vacation on 9/8/21, notified police and Department, and took Resident #1 to hospital. | |
| Staff B | Was on vacation during incident; received text about assault but did not instruct to notify police or Department. | |
| Staff E | Received report from Staff C about assault; communicated with Staff B. | |
| Staff H | Reported the incident to police and Department on 9/8/21. | |
| BB | Notified on 9/8/21 about the sexual assault; involved in resident's hospital care. | |
| AA | Interviewed and confirmed delayed reporting of the incident. | |
| CC | Accompanied Resident #1 to hospital and observed resident's behavior post-assault. |
Inspection Report
Monitoring
Deficiencies: 0
Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID 19 cases and assess infection control processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 20, 2018
Visit Reason
The purpose of this visit was to conduct an annual inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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