Failure to Timely Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse within the required two-hour timeframe to the appropriate authorities. The incident involved a resident who was found by a CNA on top of another resident in bed, with his hand inside her incontinence brief, performing jabbing motions. Both residents were clothed at the time, but the CNA observed the inappropriate behavior and called for assistance. The male resident became violent when staff attempted to remove him, striking a staff member in the process. Upon assessment, the female resident was found to have scratches and bruising on her upper legs and labia, as well as additional bruising and discoloration on her thigh and eyebrow. Facility records show that the incident was reported internally to the nursing home administrator and social worker shortly after it occurred. However, the administrator did not recognize the event as sexual abuse and did not report it to the State Department within the required two-hour window. Instead, the administrator believed there was a 24-hour reporting window and notified the State Department the following day. The incident was also not reported to local law enforcement immediately, as the administrator did not initially view it as a crime. The facility's policy, in accordance with the Elder Justice Act, requires that any suspicion of a crime involving serious bodily injury to a resident be reported immediately, but no later than two hours after the suspicion arises. The failure to report the incident in a timely manner placed the affected resident and others at risk for further harm. The survey agency identified this as Immediate Jeopardy and Substandard Quality of Care, citing the facility for not adhering to regulatory requirements for reporting alleged violations.
Removal Plan
- Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2.
- Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident.
- A CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit.
- LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted.
- Staff Development Specialist (SDS) performed a full body audit on Resident #56. The findings were red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas.
- Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received.
- NHA notified the Ombudsman of the incident.
- LMSW notified the Responsible Party (RP) of the incident.
- NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident #16 and continuing supervision.
- RP of Resident #16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement.
- LMSW verified that a CNA was placed outside Resident #16's room.
- NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone.
- A follow-up weekly body audit completed on Resident #56. No additional injuries identified.
- Primary physician notified of Resident #16 acceptance at behavioral health facility.
- NHA notified the Attorney General's Office of the incident.
- NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov.
- Resident #16 was transferred to a behavioral health facility.
- NHA notified local law enforcement of the incident.
- Local law enforcement on-site.
- Incident report received from local law enforcement.
- The Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse.
- The Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced.
- The IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced.
- No staff, including the Director of Nursing, will be allowed to work until they are in-serviced.
- An Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM.
- A Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1.
- The Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors.