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F0609
D

Failure to Timely Report Alleged Sexual Abuse to State Agency

Washington, District Of Columbia Survey Completed on 06-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to report an allegation of possible resident-to-resident sexual abuse to the state agency within the required 24-hour timeframe. The incident involved a resident with severe unspecified dementia, anxiety, glaucoma, repeated falls, and unsteadiness, who was observed being hugged, kissed, and touched over her clothing by a male resident in the hallway. The event was first documented in the resident's medical record, and staff statements confirmed the incident occurred the previous day. Despite the resident's inability to provide consent due to severe dementia, and the guardian being notified, the facility did not consider the event as sexual abuse and delayed reporting it to the state agency until two days after the initial documentation. A review of the facility's abuse prevention policy indicated that any suspicion or allegation of abuse should be investigated and reported promptly. However, documentation showed that the facility's investigation included multiple staff statements and intakes, but the required Facility Reported Incident (FRI) was not submitted to the state agency within the mandated 24-hour period. The Director of Nursing acknowledged that the facility determined the incident was not sexual abuse, which contributed to the delay in reporting.

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