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F0609
D

Failure to Timely Report Alleged Sexual Abuse and Update Abuse Reporting Policy

San Rafael, California Survey Completed on 05-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an alleged sexual abuse incident involving two residents within the required two-hour timeframe to the local ombudsman, the California Department of Public Health, and local law enforcement. The incident occurred when one resident inappropriately touched another resident, and the event was reported to the facility's dietary supervisor. However, the official report to the state was not sent until over three hours after the incident, exceeding the mandated reporting window. Both the Social Services Director and the Director of Staff Development confirmed that the report did not meet the two-hour guideline and acknowledged the importance of timely reporting for resident safety. Interviews with facility staff revealed a lack of consistent knowledge regarding abuse reporting guidelines. Licensed nurses and unlicensed staff provided varying answers about the appropriate authorities to notify and the required timeframe for reporting abuse allegations. Some staff believed that all abuse allegations should be reported within 24 hours, while others were unclear about when to involve law enforcement, indicating confusion about the current regulatory requirements. A review of the facility's abuse policy and procedure showed that it had not been updated to reflect the most recent reporting guidelines as outlined in the All Facilities Letter 21-26. The policy, last revised in 2014, did not fully align with current federal and state requirements for reporting suspected abuse, neglect, or exploitation, particularly regarding the two-hour reporting mandate for incidents involving abuse or serious bodily injury. This outdated policy contributed to the staff's inconsistent understanding and the facility's failure to report the incident in a timely manner.

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