Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to file a Self Reported Incident (SRI) with the State Agency following an allegation of sexual abuse involving a resident. The resident, who had a history of bipolar disorder, anxiety disorder, and dementia, was admitted to the facility and later referred to a gynecologist due to vaginal bleeding. The gynecologist's assessment raised concerns about a potential sexual assault, as the resident had reported being sexually active with her husband and had experienced bleeding after intercourse. Despite these concerns, the facility did not report the incident to the State Agency as required by their policy. The facility's policy mandates that any event involving abuse or serious bodily injury should be reported to the State Agency immediately, or no later than two hours after the allegation is made. However, an interview with the Administrator confirmed that no SRI was filed following the gynecologist's documented allegation of potential sexual assault. This oversight represents a deficiency in the facility's compliance with state reporting requirements, as investigated under Complaint Number OH00162528.
Plan Of Correction
Resident has had no further vaginal bleeding. Skin assessment of resident was completed on 3/3/25 by staff nurse with no suspicious findings. Medical record was reviewed by ADON on 3/7/25 and resident has had no decline in status as evidenced by stable mood and behavior, no decline in intakes, and no other decline in status. All current resident records were reviewed by ADON, unit manager or MDS to identify any suspicious injuries/injuries of unknown source. None were identified. This review was completed on 3/7/25. Administrator reviewed facility complaints for the last 3 months on 3/7/25 and there were no complaints that were suspicious for abuse. The facility did not identify any other reportable events from the complaints or medical record reviews. Administrator and DON were educated on 3/11/25 on reporting to State Agency as outlined in the facility policy by the Corporate DON. See inservice attached. To ensure ongoing compliance, the facility administrator will review all complaints and any injuries without a known cause weekly with Corporate DON x 4 weeks. The results of these reviews will be forwarded to the QAPI Committee to determine a schedule for ongoing monitoring or additional interventions.