Failure to Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to ensure that allegations of sexual abuse involving five residents were reported to the State Agency as required. Multiple incidents were documented in clinical records and staff interviews, including inappropriate touching, sexualized behaviors, and physical aggression by one resident towards several female residents, all of whom had varying degrees of cognitive impairment. Staff observed and documented these behaviors, such as a resident rubbing another's legs, attempting to take female residents to his room, and grabbing buttocks, but these incidents were not consistently reported to the appropriate authorities. Interviews with staff revealed a lack of clarity and consistency in reporting procedures. Some staff members, including CNAs and housekeepers, witnessed or were informed of inappropriate behaviors and reported them to their immediate supervisors or unit managers. However, these reports were not always escalated to the Director of Nursing or the Abuse Coordinator, as required by facility policy. In several cases, staff made subjective decisions about whether incidents were reportable, often based on whether physical harm was observed, rather than following the policy to report all allegations of abuse immediately. Facility documentation and policy review confirmed that the policy required immediate reporting of all abuse allegations to local, state, and federal agencies, as well as internal leadership. Despite this, the Abuse Coordinator and DON were not informed of several incidents, and no reports were filed with the State Agency for the sexual abuse allegations involving the five residents. The deficiency was further evidenced by interviews with the DON and Abuse Coordinator, who were unaware of the full extent of the incidents until informed by surveyors.