Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported within the required two-hour timeframe to the administrator and State Survey Agency (SSA), as mandated by federal and state regulations. Specifically, a female resident with a history of anxiety disorder, depression, and recent joint replacement surgery reported to staff that a neighboring male resident had exposed himself and masturbated at her doorway on multiple occasions. The resident was cognitively intact at the time, as indicated by a recent BIMS score of 15. Despite the resident reporting these incidents to multiple staff members, including a CNA and an LVN, the allegations were not promptly reported to facility leadership or the SSA. The CNA who received the initial reports from the resident stated that she informed the LVN on at least two separate occasions, but the LVN was dismissive and attributed the allegations to resident confusion. The LVN did not report the allegations to the administrator or initiate an investigation, believing the matter was already known or not credible. The social worker only became aware of the incident through a third-party professional and subsequently notified the administrator and initiated an assessment. The administrator confirmed that she was not notified by staff and only began an investigation after being informed by the social worker, well after the initial allegations were made. The facility's internal investigation confirmed the identity of the alleged perpetrator, a male resident with severe cognitive impairment and a history of wandering and inappropriate behavior. However, the incident was not documented in the facility's incident report log for the relevant month, and there was no evidence that the incident was reported to the SSA as required. Interviews with facility leadership revealed uncertainty about reporting requirements and a lack of immediate notification procedures, despite existing policies mandating prompt reporting of abuse allegations.