Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged sexual abuse involving a resident, identified as R110, to the State Agency and the Administrator as required. The incident involved another resident, R34, who entered R110's room and engaged in inappropriate sexual behavior. R110, who was cognitively intact with a BIMS score of 15, reported the incident to the staff and completed a grievance form. However, the facility did not take immediate action to report the incident to the necessary authorities. The facility's policy on abuse investigation and reporting mandates that any allegations of abuse, neglect, or exploitation must be reported immediately to the Administrator and the State Agency. Despite this policy, the Director of Nursing confirmed that the Administrator was not notified of the incident immediately, and the incident was not reported to the State Survey Agency as required. The failure to report was only rectified after the surveyor brought the issue to the facility's attention. Interviews with the Director of Nursing revealed a lack of awareness regarding the details of the incident, such as the exposure and masturbation by R34. The facility's documentation showed that the incident was reported late, and the grievance form filled out by R110 did not result in timely action. This oversight in reporting and addressing the incident highlights a significant deficiency in the facility's adherence to its own policies and federal/state requirements for handling allegations of abuse.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The alleged violation was reported to the state agency. The DON/designee conducted a 2-week look back of incident reports and grievance reports to ensure any abuse allegations made were reported to the state survey agency as required. The DON/designee educated staff on the abuse policy. The DON/designee will audit incident reports and grievance reports to ensure any abuse allegations made are reported to the state survey agency as required. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.