Failure to Timely Report Sexual Abuse Incident
Penalty
Summary
The facility failed to report an act of sexual abuse involving two residents within the required two-hour timeframe as outlined in its Abuse Prevention and Management policy. The incident occurred when a registered nurse (RN) observed one resident on top of another in a resident's room, with the victim's pants down and the perpetrator's face near the victim's genital area. The RN intervened immediately and separated the residents. Despite being aware of the incident, the RN did not report it to the California Department of Public Health (CDPH) or the police, as required, after being told by the Director of Nursing (DON) that the Administrator (ADM) would handle the reporting. The victim had a history of schizophrenia, major depressive disorder, and anxiety disorder, and was assessed as unable to make medical decisions but able to make needs known. The Minimum Data Set indicated no cognitive impairment and a need for partial to moderate assistance with activities of daily living. The perpetrator was newly admitted, alert, and had no cognitive or physical impairments noted. The incident was documented in the Interdisciplinary Team meeting notes, and both the RN and ADM acknowledged during interviews that the event should have been reported to the appropriate authorities within two hours, as per facility policy. A review of the facility's policy confirmed that any allegation of abuse, including those without serious bodily injury, must be reported by telephone and in writing to CDPH, the Ombudsman, and law enforcement within two hours. The failure to report the incident in a timely manner delayed the investigation by CDPH and placed other residents at risk for abuse, as explicitly stated in the findings.