Failure to Protect Resident from Abuse and Inadequate Reporting of Allegation
Penalty
Summary
The facility failed to ensure that a resident was protected from abuse, neglect, and exploitation after the resident reported an incident of sexual abuse by a certified nursing assistant (CNA). The resident, who had vascular dementia, hemiplegia, hemiparesis, and required maximal assistance with activities of daily living, alleged that the CNA inappropriately touched him during a shower. The resident initially did not report the incident due to embarrassment but later disclosed it to staff. Despite this disclosure, the alleged perpetrator was not suspended, and the allegation was not investigated or reported to local law enforcement or the State Agency as required by facility policy and regulations. Multiple staff members became aware of the allegation through direct disclosure by the resident or through communication among staff. However, there was a breakdown in the reporting process, as some staff assumed others had reported the incident, and key individuals, including the ADON and charge nurse, did not ensure the allegation was escalated to the Administrator or documented appropriately. The Administrator stated she was not notified of the allegation and denied any knowledge of the incident. There was no documentation of the allegation in the resident's progress notes, 24-hour reports, or self-reports to the state agency during the relevant period. The facility's own abuse and neglect policy required immediate suspension of the alleged perpetrator, prompt investigation, and timely reporting to authorities, none of which occurred following the resident's report. The only action taken was to restrict male staff from providing care to the resident, without further investigation or protective measures for other residents. This failure to follow established protocols resulted in an Immediate Jeopardy situation, as residents were not protected from potential further abuse or harm.