Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report multiple allegations of sexual abuse by a staff member to the Abuse Coordinator and/or State Survey Agency in a timely manner. This involved a resident, identified as R801, who exhibited signs of fear and distress when a male CNA continued working after the allegations were made. The allegations included inappropriate touching of R801's breasts and genital area by a male staff member, which were not promptly reported to the appropriate authorities, resulting in a delay in investigation. The report details that the complainant initially did not report the first incident, thinking R801 was confused. However, after a second incident where R801 mentioned the inappropriate touching in front of the alleged perpetrator, the complainant reported it to the Administrator. Despite this, the Administrator did not take immediate action, leading the complainant to contact the State Agency. The facility's failure to act promptly allowed the alleged perpetrator to continue working, causing further distress to R801. Interviews with various staff members revealed a lack of communication and failure to follow protocol in reporting the allegations. Staff members were aware of the allegations but did not ensure they were reported to the Administrator or Abuse Coordinator. The Administrator only became aware of the situation when the police arrived to investigate, prompted by an anonymous report to Adult Protective Services. The facility's policy required immediate reporting of such allegations, which was not adhered to, resulting in a significant delay in addressing the serious allegations of abuse.
Plan Of Correction
Element 1 - R801 no longer resides in the facility. - Facility unable to identify an allegation of abuse for the "unidentified resident." Element 2 - On 3/12/2025, all residents who are able to report abuse were queried about feeling safe and free from abuse by staff. No additional concerns and/or allegations noted. - For residents who are unable to report abuse, skin assessments were completed by a licensed nurse for any signs or symptoms of abuse. - This was completed on 3/12/2025. Root Cause: Facility did not follow the Abuse, Neglect, and Exploitation Policy. Element 3 - The Abuse, Neglect, and Exploitation Policy was reviewed by QAPI Committee on 3/12/25 and deemed appropriate. - Staff were re-educated on the Abuse, Neglect and Exploitation policy by management staff with emphasis on types of abuse, reporting abuse, and also included staff testing after education, and an in-service card being handed out. - This was completed by 3/17/2025 or prior to their next scheduled shift. Element 4 - Random weekly audits of staff will be conducted for 4 weeks, then monthly thereafter to ensure there are not any allegations of abuse until substantial compliance is obtained. - Results of the audits will be brought to the QAPI committee for monthly review and will only be discontinued with substantial compliance and the approval of the facility's QAPI committee. - Administrator is responsible to maintain compliance.