Failure to Report Alleged Sexual Abuse to Required Authorities
Penalty
Summary
The facility failed to report an incident of alleged sexual abuse involving a resident with significant cognitive impairment, as required by both facility policy and regulatory guidelines. The resident, who had diagnoses including Alzheimer's dementia, anxiety, depression, and a vertebral fracture, was unable to be interviewed due to cognitive limitations. The incident was brought to attention when the resident's stepdaughter observed the resident becoming upset with a CNA, mistaking the CNA for the stepdaughter's husband. The spouse of the resident did not express concern about the incident, but the facility's investigation was limited to internal review without notifying all required external authorities. Despite the facility's policy mandating immediate reporting of suspected abuse to the administrator, state agencies, ombudsman, Adult Protective Services, law enforcement, the resident's representative, and medical professionals, the facility did not notify the police, Adult Protective Services, or the ombudsman. Staff interviews revealed confusion about reporting requirements, with some believing that internal investigation and state notification were sufficient. The administrator and DON deferred to the family's wishes not to involve police or send the resident for a hospital evaluation, contrary to policy. The ombudsman and other staff expressed concern about not being informed or involved in the process.