Failure to Identify, Investigate, and Report Sexual Abuse Incident
Penalty
Summary
The facility's Administrator failed to identify and report an incident of sexual abuse in a timely manner to the State Agency, as required by federal and state regulations. According to the report, an LPN observed a resident with severely impaired cognition, who lacked the capacity to consent, being approached inappropriately by another resident who was nude from the waist down and caressing the resident's hip and thigh. The Administrator did not promptly recognize this as sexual abuse, nor did he initiate a thorough investigation as outlined in the facility's abuse policy. Interviews and record reviews revealed that the Administrator, who also served as the Abuse Coordinator, did not follow the established procedures for investigating allegations of abuse. The Administrator admitted that not all witness statements were collected and that the facility had not thoroughly investigated all incidents reviewed by the survey team. He also acknowledged that he had not received training on the abuse policy upon assuming his role, despite being responsible for reporting, investigating, and following up on all abuse allegations. The deficiency was cited under F835-Administration, as the Administrator's actions and inactions resulted in non-compliance with requirements of participation, causing or likely to cause serious harm or psychosocial harm to residents. The failure to properly investigate and report the incident had the potential to affect all residents in the facility, as it demonstrated a breakdown in the facility's system for protecting residents from abuse.