F0609

J

Failure to Timely Report and Investigate Alleged Sexual Abuse

El Paso, Texas Survey Completed on 04-11-2025

Penalty

Fine: $11,615

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made. Specifically, a male resident with vascular dementia, hemiplegia, hemiparesis, and moderate cognitive impairment reported to staff that a certified nursing assistant (CNA) had sexually abused him during a shower. The resident initially delayed reporting the incident due to embarrassment, but later informed staff members, who did not immediately escalate the allegation to the facility administrator or law enforcement as required by policy and regulation.

Multiple staff interviews revealed that the resident's report of sexual abuse was communicated among staff, including a medication aide, charge nurse, and assistant director of nursing (ADON), but there was confusion and lack of clarity regarding who was responsible for notifying the administrator and external authorities. The ADON stated that he informed the administrator by phone, but the administrator denied receiving any such report or having knowledge of the allegation. Documentation review showed no record of the abuse allegation in the resident's progress notes, 24-hour reports, or self-reports to the state survey agency during the relevant period. The CNA accused of abuse continued to work in the facility and was not suspended until months after the initial allegation.

The facility's abuse/neglect policy required immediate reporting of all allegations to the administrator and appropriate authorities, but this protocol was not followed. Staff interviews indicated inconsistent understanding and execution of reporting procedures, with some staff assuming others had reported the incident. The lack of timely and proper reporting resulted in a failure to protect residents from potential further harm and did not meet regulatory requirements for abuse allegation management.

Removal Plan

• Abuse allegation investigations are ongoing. All new investigations start immediately upon receiving an allegation.
• The resident was interviewed at the time of discovery and a trauma informed care assessment was completed by the DON. Results were no negative outcomes.
• One on One in-service on Abuse Reporting with the Administrator, DON, by Area Director of Operation (ADO).
• One on One in-service on Investigating allegations with the Administrator, DON, by ADO.
• Staff working with alleged perpetrators have been interviewed by the Administrator, Director of Nursing, ADO, and Compliance Nurse.
• The alleged perpetrator was suspended, pending the outcome of the investigation.
• The ADON was suspended, pending the outcome of the investigation.
• Notification of Authorities: Law enforcement and HHSC were notified promptly in accordance with state-mandated reporting guidelines.
• Emotional Support: Social services and/or a mental health provider were contacted to provide counseling and emotional support to the resident; referral was sent.
• All residents who were able to be interviewed had safety surveys by the social worker. No abuse incidents were reported.
• All residents who were able to be interviewed were interviewed by DON/Compliance Nurse/Social worker. A new skin assessment was completed on all non-verbal residents by the same group with no abnormal findings.
• The following in-services were initiated by the Administrator/ADO: Any staff member not present or in-service will not be allowed to assume their duties until in-service.
• All Staff in-serviced on: Abuse/Neglect with special focus on sexual abuse; Abuse/Neglect Reporting; Who to Report Abuse/Neglect to Administrator and Director of Nursing. A second layer of reporting was added to prevent oversight of a single individual.
• All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report.
• The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services.
• New staff will be in service during orientation before assuming any duties.
• The medical director was notified of the immediate jeopardy situation.
• The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review.
• The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents to ensure resident safety/satisfaction with the outcome of the investigation.
• The Area Director will monitor abuse allegations reported by residents and or staff and check the real-time system, which monitors keywords like abuse documentation and PCC for any incidents and accidents.
• The QA committee will review the findings of abuse allegations and investigations monthly and make changes to the system as needed until substantial compliance is achieved.