Failure to Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident sexual abuse to the state agency, as required by both state regulations and facility policy. The incident involved two residents, one with severe cognitive impairment and behavioral issues, and another with a history of psychiatric disorders and sexually inappropriate behaviors. Multiple documented events indicated ongoing sexually inappropriate interactions between these two residents, including reports of oral sex, physical contact, and repeated attempts to enter each other's rooms. Staff were made aware of these incidents through progress notes, resident reports, and direct observation. Despite the repeated documentation of these behaviors and the involvement of various staff members, including LPNs, RNs, the Social Service Director, and the DON, there was no evidence that the facility submitted a self-reported incident (SRI) to the state agency regarding the sexual abuse allegations. The facility's own policy required notification of the Ohio Department of Health (ODH) within 24 hours of any alleged violations involving abuse, neglect, or exploitation. Interviews with facility leadership confirmed that no SRI was completed for these incidents. The medical records and care plans for both residents were updated to reflect the ongoing behaviors, and interventions such as 15-minute checks, education on safe sex practices, and behavior contracts were implemented. However, the lack of timely reporting to the appropriate authorities constituted a failure to comply with regulatory requirements for reporting suspected abuse, neglect, or theft, as well as a failure to follow the facility's own policies.