Failure to Report Suspected Abuse in a Timely Manner
Summary
The facility failed to report suspected abuse, neglect, or mistreatment in a timely manner, as required by state law and facility policy. A resident, who was cognitively impaired and unable to make decisions, was found with unexplained vaginal bleeding on two separate occasions. On the first occasion, the bleeding was noted by a CNA and reported to an RN, who then notified the Nurse Practitioner and the Assistant Director of Nursing but failed to report the incident to the facility's Abuse Coordinator. On the second occasion, the resident was found with significant vaginal bleeding and was transferred to a hospital, where semen was found in her urine sample, indicating possible sexual abuse. Despite these findings, the incident was not reported to the Abuse Coordinator or other authorities as required. Interviews with facility staff revealed a lack of understanding and adherence to the facility's abuse reporting policies. Several staff members, including CNAs, RNs, and the Interim Director of Nursing, failed to recognize the signs of potential sexual abuse and did not report the incidents to the facility's Abuse Coordinator. The Administrator, who was also the Abuse Coordinator, was unaware of the incidents until informed by the State Survey Agency. The facility's policy required immediate reporting of suspected abuse to the Administrator and other officials, but this was not followed, leading to a delay in addressing the potential abuse. The facility's failure to report the incidents promptly resulted in an Immediate Jeopardy situation, as identified by the surveyors. The lack of timely reporting and investigation of the incidents placed residents at risk for further abuse, neglect, or mistreatment. The facility's policies and procedures for reporting and investigating abuse were not effectively implemented, as evidenced by the staff's failure to report the incidents and the Administrator's lack of awareness of the situation.
Removal Plan
- The facility administrator completed a self-report incident to HHSC due to allegation of sexual abuse.
- A police report was made, they arrived at the facility to collect resident demographics.
- The facility nursing management staff initiated skin assessment focusing on peri-area to ensure no trauma or signs of physical injuries were present in all residents - no issues noted.
- The facility DON/Designee assessed male residents who can ambulate, self-transfer and who wander in the facility and other residents' rooms. One resident was placed on 1:1 supervision due to wandering. Discharge process initiated.
- The facility Adm/DON/SW or designee initiated 1:1 interviews with facility staff and residents focusing on observation prior to the resident transfer to the hospital. Questionnaire revealed no unusual circumstances noted by staff or residents.
- The facility Social Worker/Designee conducted life safety interviews with all interviewable residents. Interviews revealed no new negative events.
- The President of Operation conducted an in-service with the facility Administrator: Review of State Reportable guidelines Provider Letter to ensure understanding of reportable incidents including timeline, i.e.: Abuse is to be reported immediately but no later than 2 hours.
- The IDON/Designee initiated an in-service with the facility staff on Abuse and Neglect Facility Expectations based on policy. This included an explanation of the definition of Abuse, Neglect and sexual abuse and symptoms.
- The IDON/Designee initiated an in-service with the facility staff on Possible Signs and Symptoms of Sexual Abuse including indicators, how to detect sexual abuse.
- The IDON/Designee initiated an in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting, and documentation.
- The IDON/Designee initiated an in-service with facility staff on: Who is the facility abuse prevention coordinator, notifications of suspected abuse and neglect including sexual abuse signs and symptoms are to be reported to the administrator immediately.
- The DON/Designee initiated an in-service with staff on immediately reporting any new residents' unusual behaviors, fear, crying, guarding, complaint of pain in pelvic area, isolation, etc.
- Any staff member not present or in service will not be allowed to assume their duties until in-serviced. Ongoing in-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, PRN, and agency staff is completed.
- The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire.
- An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with dementia, bipolar disorder, vertebral fractures, and intact cognition alleged that two CNAs were rough during a bed bath, twisting her leg and jumping on her bed and legs. The resident first told a medication aide that a CNA was rough, but the aide continued passing medications and did not immediately report the allegation to the charge nurse or administrator, and multiple LVNs and the ADON confirmed they did not receive this report. Days later, the resident repeated the allegation to another medication aide, who informed the implicated CNA instead of promptly notifying the LVN or administrator; the CNA then reported to the LVN, who attempted to contact leadership. The administrator stated she did not become aware of the allegation until many days after the incident, and the facility’s investigation documented that the event occurred well before it was reported to the state. Staff interviews and the facility’s abuse protocol showed that all staff understood that rough treatment could be abuse and that such allegations must be reported immediately, yet the required immediate reporting process was not followed, resulting in delayed internal and external reporting of the alleged abuse.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
The facility failed to timely report alleged abuse to SSA and APS after staff twice observed a resident with dementia and acute systolic CHF receiving zealous, open-mouthed kisses on the mouth from her brother. On two separate occasions, a CNA and an LPN witnessed or were informed of these unusual kissing interactions, which they later described as awkward and not typical of a sibling relationship. Despite this, the nursing staff did not immediately report the incidents as potential abuse to the Administrator, and the allegation was not brought forward until a staff meeting days later, resulting in the required notifications to external authorities not being made within the mandated 2-hour timeframe.
A resident with a traumatic brain injury, subdural hematoma, and cervical fracture reported to an RN that during care he was boosted in bed, his head struck the headboard, and he experienced increased numbness and tingling in his left forearm and fingers, with pins and needles in his upper extremities and feet. The RN documented the complaint and noted no obvious head injury, no increased pain, and an intact CTO brace with a missing foam piece, and the resident’s care plan called for caution during transfers and bed mobility. However, nursing staff did not enter an incident report or initiate an investigation of this allegation of potential rough handling/abuse as required by facility policy and state law, and the event was not reported to administration until the family later raised concerns, at which point leadership confirmed the failure to immediately report and investigate.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Immediately Report Resident’s Allegations of Rough Care and Possible Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property were reported immediately, and no later than two hours after the allegation was made, to the administrator and appropriate state officials. One resident with metabolic encephalopathy, Alzheimer’s dementia, anxiety, multiple vertebral compression fractures, pain, and bipolar disorder, who was cognitively intact per a BIMS score of 14, alleged that two CNAs were rough during a bed bath, twisted her leg, and jumped on her bed and legs. The resident’s care plan noted impaired cognitive function/dementia and later documented verbal behavior symptoms directed toward others, including allegations that staff attacked her, followed by expressions of affection for the same staff. The facility’s investigation identified the incident date as early in the month when two CNAs provided a bed bath, and the facility documented that it did not become aware of the allegation until later in the month, at which time the allegation was reported to the state. According to staff interviews and statements, the resident first voiced concerns about rough care on a date several days after the bed bath, when a medication aide (MA A) reported that the resident said a CNA was rough with her. MA A stated she told the resident she did not think the CNA would be rough, then continued passing medications and did not immediately report the allegation to the administrator or clearly to the charge nurse, DON, ADON, or other leadership, despite acknowledging that rough treatment could constitute abuse and that such allegations were to be reported immediately. Multiple nurses (LVN F, LVN G, and the ADON) stated that MA A did not report this allegation to them on that date, and each indicated that they would have reported any such allegation to the administrator immediately. The facility’s abuse protocol required any person observing or suspecting abuse to immediately report to the charge nurse, who must then immediately examine the patient and notify the Abuse Prevention Coordinator. Several days later, the resident again reported to another medication aide (MA E) that a CNA and another aide were rough during care and that her legs hurt because the aides were jumping up and down on her legs. MA E acknowledged that she did not report this allegation directly and immediately to the LVN or administrator, but instead informed the implicated CNA, who then reported the allegation to the LVN on duty (LVN D). LVN D stated that upon being informed by the CNA, she attempted to contact the administrator and then informed the ADON. The administrator reported that she first became aware of the allegation at approximately 4:40 p.m. on that later date, and the facility’s investigation form reflected that the incident had occurred many days earlier. Staff interviews and time card reviews confirmed the dates the CNAs worked and the timing of the bath relative to the resident’s subsequent complaints. The failure of MA A and MA E to follow the facility’s abuse protocol and immediately report the resident’s allegations to the charge nurse and administrator resulted in a delay in the facility’s awareness and reporting of the alleged abuse. In their statements, the CNAs involved (CNA B and CNA C) described providing a routine bed bath to the resident, noting that she complained of being wet and cold but did not complain of pain during the bath, and they denied hurting her or jumping on her bed or legs. They also stated that they were not informed of any complaint until many days after the bath. The resident, when interviewed later, reiterated that the aides were rough, twisted her leg, and jumped on the bed, and said she did not want them providing her care, although she could not recall the exact date or which staff member she initially told. The administrator, LVN D, CNAs, and medication aides all acknowledged in interviews that rough treatment could be considered abuse and that allegations of abuse must be reported immediately. Despite this, the facility’s own records and staff accounts showed that the initial allegation made to MA A and the subsequent allegation made to MA E were not promptly reported through the required chain, resulting in the facility not becoming aware of and not reporting the allegation to the state survey agency within the required timeframe.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Timely Report Alleged Sexual Abuse to SSA and APS
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Resident 3, who was admitted with unspecified dementia and acute systolic congestive heart failure, was involved in two separate incidents in which her brother was observed kissing her on the mouth in a manner staff described as zealous, enthusiastic, sloppy, and not typical of a brother-sister interaction. On 12/28/25, CNA 1 observed a well-dressed man enter Resident 3's room, hug her, and give her a zealous kiss on the mouth. CNA 1 assumed the man was the resident's husband and reported this to LPN 1, who knew the visitor was the resident's brother. LPN 1 looked into the room and did not see anything out of the ordinary, and neither CNA 1 nor LPN 1 reported this incident as a potential allegation of abuse to the Administrator at that time. On 1/4/26, LPN 1 and CNA 1 entered Resident 3's room to address the resident's pain and request for catheter removal and to assist with a brief and linen change. Resident 3 had two visitors present, including her brother. When asked to step out for privacy, the female visitor left, but the brother hesitated and then gave Resident 3 a sloppy, open-mouthed kiss on the mouth lasting about three seconds, again in the presence of staff. The brother stated that Resident 3 was his older sister and that she had taken care of him since they were very small. LPN 1 did not report either the 12/28/25 or 1/4/26 kissing incidents to the Administrator. The Administrator later stated that the alleged abuse was first mentioned during a meeting on 1/6/26, at which time staff described the kiss as a weird, awkward kiss and not a typical brother-sister kiss, and acknowledged that nursing staff had not reported the suspicious activity in a timely manner, resulting in failure to notify SSA and APS within two hours of the allegation.
Failure to Immediately Report and Investigate Resident Allegation of Rough Handling
Penalty
Summary
The deficiency involves the facility’s failure to immediately report and investigate a resident’s allegation of potential abuse/neglect as required by policy and state law. Facility policy (RISKWATCH Incident/Accident Occurrence Reporting System) required that incidents such as alleged abuse, rough handling, equipment-related incidents involving a resident, and injuries of unknown origin be entered completely and accurately by the licensed nurse or first responder prior to the end of the shift and as close to the time of the incident as possible, with documentation on the 24-hour report and alert monitoring per change of condition standards. A resident with diagnoses including traumatic subdural hematoma, displaced fracture of the seventh cervical vertebra, and traumatic brain injury reported to an RN that during care the previous night, when he was being boosted in bed, his head hit the headboard and he was experiencing increased numbness and tingling in his left forearm and first and second fingers, with pins and needles in the left upper extremity, right hand, and both feet. The RN documented that there was no obvious head injury or increased pain and that the cervical-thoracic orthosis brace was intact, though missing a foam piece underneath the bottom portion. Despite this report from the resident, and the resident’s plan of care indicating he had potential/actual impairment related to a cervical collar and impaired mobility requiring use of caution during transfers and bed mobility to prevent striking extremities against hard or sharp surfaces, the nursing staff did not make an incident report or initiate an investigation at that time. The Nursing Home Administrator confirmed that the resident and family reported the event to nursing staff on the date of the RN’s note without staff making a report in accordance with facility policy and state requirements. An investigation was not initiated until later, after the family emailed facility administration with concerns related to the event. The Nursing Home Administrator and Director of Nursing acknowledged that the facility failed to immediately report and investigate the resident’s allegation in response to allegations of abuse, neglect, exploitation, or mistreatment.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
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