Failure to Report and Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not reporting multiple allegations of sexual abuse and inappropriate behaviors involving several residents to the State Agency. The report details repeated incidents where one resident, with a history of dementia, agitation, and behavioral disturbances, engaged in sexually inappropriate and aggressive behaviors towards female peers, including touching, kissing, rubbing, and attempting to lead them to his room. These behaviors were observed and documented by various staff members, including CNAs, LPNs, and housekeeping staff, and were sometimes witnessed by other residents' family members. Despite these observations, there was a lack of consistent documentation in the residents' records and no evidence that these incidents were reported as required by facility policy. Interviews with staff revealed a breakdown in communication and reporting procedures. Several staff members, including CNAs and housekeeping, reported incidents to their immediate supervisors or unit managers, but these reports were not escalated to the Director of Nursing (DON) or the Abuse Coordinator as required. The Abuse Coordinator stated he did not file a report with the state agency because he was not fully informed of the details, and the unit manager indicated she did not feel the incidents warranted further reporting since no one was visibly hurt or in distress. This resulted in the DON and Abuse Coordinator being unaware of the full extent of the resident's behaviors and the ongoing risk to other residents. The facility's policy clearly states that all allegations of abuse, neglect, or exploitation must be reported immediately to the appropriate authorities, including the state agency, within two hours. However, the report demonstrates that this policy was not followed, as multiple incidents involving inappropriate sexual contact and aggression were not reported or investigated according to protocol. The lack of timely and appropriate reporting could result in continued resident-to-resident abuse and a failure to protect vulnerable residents with severe cognitive impairments and behavioral issues.