Failure to Report and Investigate Allegation of Sexual Harassment
Penalty
Summary
A deficiency occurred when the facility failed to ensure the immediate reporting and investigation of an allegation of sexual harassment made by a resident. The resident, who was cognitively intact with a BIMS score of 13, reported that a male occupational therapy assistant entered her room while she was undressed, despite her telling him to leave. She described feeling sexually harassed and abused by the incident and communicated her concerns to a female supervisor and the DON, stating she did not want the staff member in her room anymore. Despite the resident's clear report of feeling sexually harassed, there was no evidence in the facility's state agency reportable log that a report was filed or that an investigation was conducted regarding the allegation. Interviews revealed conflicting accounts between the Director of Rehabilitation and the DON regarding whether the allegation was communicated and acted upon. The Director of Rehabilitation stated she reported the incident to the DON, while the DON denied receiving any report of sexual harassment and stated that, had she been informed, she would have suspended the staff member and initiated an investigation. The facility's policy required staff to report any allegations of abuse, neglect, exploitation, or mistreatment immediately to the risk manager, direct supervisor, or abuse coordinator, and to report such allegations to state agencies within the required federal timeframes. However, in this case, the required procedures were not followed, resulting in the failure to report and investigate the resident's allegation of sexual harassment as mandated by federal regulations.
Plan Of Correction
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.