Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to immediately report allegations of sexual abuse to the Abuse Coordinator and did not timely notify the State Agency regarding a suspected abuse incident involving a resident with severe cognitive impairment and multiple medical conditions. The resident, who was dependent on staff for all activities of daily living, was observed by staff to have vaginal bleeding and swelling, and exhibited increased distress during perineal care. Staff notified the DON and the on-call provider, who recommended hospital evaluation, but did not clearly communicate suspicion of possible abuse to the facility administration at that time. The resident was transported to the hospital, where a rape test was ordered and the police were notified by hospital staff due to suspicion of sexual abuse. The facility administrator was not made aware of the potential abuse until the police arrived at the facility, having been contacted by the hospital. It was only after speaking with the resident's legal guardian and learning of the hospital's actions that the administrator recognized the need to initiate an internal investigation and report the incident to the State Agency. The delay in reporting resulted in a late start to the facility's investigation and a failure to promptly assess other residents for potential abuse. The State Agency was not notified of the allegation until the day after the incident, and the facility's own investigation and interviews with staff and residents were not initiated until after the administrator became aware of the situation from external sources.