Failure to Report and Investigate Alleged Sexual Harassment
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the reporting of a reasonable suspicion of a crime, as required by federal and state regulations, for one resident out of four sampled. The deficiency centers on an incident involving a resident who reported feeling sexually harassed and abused by a male Occupational Therapist Assistant (OTA) after he entered her room while she was undressed. The resident stated that she told the OTA to leave, which he did, and subsequently refused therapy with him. She reported the incident to a female supervisor and the DON, expressing that she did not want the OTA in her room anymore and described her feelings of harassment and abuse. Interviews with facility staff revealed inconsistencies in the communication and handling of the resident's allegation. The Director of Rehabilitation stated that the resident reported the incident to her, and she subsequently interviewed the OTA and relayed the information to the DON, who is the facility's abuse coordinator. However, the DON denied receiving any report of sexual harassment or abuse from the Director of Rehabilitation, stating that the only concern brought to her attention was the resident's preference for a therapy schedule and not wanting certain therapists. The DON confirmed that if an allegation of abuse or sexual harassment had been reported, she would have suspended the staff member, reported the allegation, and initiated an investigation, none of which occurred. A review of the facility's state agency reportable log showed no evidence that a report was filed with state agencies or that an investigation was conducted regarding the resident's allegation. The facility's policy requires staff to report any allegations of abuse, neglect, exploitation, or mistreatment immediately to the appropriate personnel and to state agencies within the required timeframe. Despite these policies, the incident involving the resident and the OTA was not reported or investigated as required, resulting in noncompliance with federal and state regulations.
Plan Of Correction
N917 Resident #3 abuse allegation was reported, an investigation conducted, and investigative findings confirm unsubstantiated for sexual abuse. Resident #3 discharged home as planned and no longer resides in the facility. The facility DOR and Staff C no longer are employed at the facility. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Like resident interviews conducted with no reported concerns regarding sexual abuse or care concerns. Process of reporting abuse, neglect, and exploitation reviewed with residents at Resident council by 7/12/2025. Staff interviews and education conducted to ensure no reported allegations of abuse, neglect, or exploitation. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. The administrator educated the DON on reporting requirements of abuse, neglect, and exploitation allegations with competencies. 2. The administrator and/or designee educated staff on reporting requirements to the facility abuse coordinator of allegations of abuse, neglect, and exploitation with staff competencies. 3. Newly hired staff will be educated on reporting requirements to the facility abuse coordinator of abuse, neglect, and exploitation allegations and the facility abuse coordinator. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents on each unit. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The administrator and/or designee will conduct random 10 staff interviews for competencies on reporting allegations of abuse, neglect, and exploitation. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met. This plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.