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F0609
D

Failure to Timely Report Alleged Sexual Abuse to State Agency

Saint Louis, Missouri Survey Completed on 04-25-2025

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 notify the State Survey Agency within the required two-hour timeframe after an allegation of sexual abuse was made by a resident. According to the facility's policy, all allegations or suspicions of abuse, neglect, or exploitation must be reported immediately to the Administrator and the State Agency. In this incident, a resident reported to a CNA that another resident had entered their room and touched their genitalia while they were sleeping. The CNA promptly reported the allegation to the nurse, who then documented the resident's account, which included some uncertainty about the details due to the resident's confusion and distress. The resident involved was cognitively intact and able to express themselves clearly, with a history of mental health diagnoses including anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. The incident was described as causing the resident significant distress, particularly because it resembled a previous event at another facility. The nurse's documentation noted inconsistencies in the resident's account, as the resident changed details about the incident multiple times before and after emergency services were contacted. Despite the facility's policy requiring immediate reporting, the self-report to the State Agency was not made until the following morning, several hours after the initial allegation was brought to staff attention. The DON confirmed that the report was made within two hours of her being notified, but the initial delay in escalating the allegation to the DON resulted in the facility failing to meet the required reporting timeframe.

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