Failure to Timely Report Allegations of Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to ensure that allegations of sexual abuse involving three residents were reported to the state survey agency (SSA) within the required two-hour timeframe, as outlined in the facility's own Abuse Prohibition-Reporting and Investigating policy. In the first incident, a staff member observed a resident masturbating and rubbing another resident's leg in a common area. Although the incident was reported to a charge nurse and documented in the nursing notes, the Administrator was not informed until several days later during a chart review. Staff members involved each believed the other would report the incident, resulting in a significant delay in notifying the SSA. In the second case, a staff member found a resident in distress and pointing to their genital area after being alone with another resident. The staff member reported the situation to a nurse and then called the Administrator, who was not on site. The Administrator instructed a nurse to interview the resident but did not immediately recognize the situation as an abuse allegation requiring prompt reporting. The incident was only reported to the SSA after the resident communicated to the nurse that something had happened, leading to uncertainty about the actual time of the event and the timeliness of the report. The third incident involved a staff member witnessing a resident rubbing another resident's inner thigh. The staff member promptly notified the DON and the physician, and the DON notified the Administrator. However, the Administrator delayed reporting to the SSA while seeking additional information and consulting with a clinical consultant. The incident report contained conflicting times, and the SSA was not notified within the required two-hour window. In all three cases, the facility did not adhere to its policy or federal requirements for timely reporting of abuse allegations.