Failure to Report Alleged Sexual Abuse of Cognitively Impaired Residents
Penalty
Summary
The facility failed to report allegations of sexual abuse involving two male residents who were severely cognitively impaired and unable to consent. According to the facility's policy, all allegations of abuse or those involving serious bodily injury must be reported immediately, but no later than two hours. Despite this, incidents involving inappropriate hypersexual behaviors by a female resident with a known history of such behaviors were not reported to the State Agency. The female resident had a documented history of sexually inappropriate behaviors towards men and was assessed as having moderately impaired cognition. The two male residents involved had severe cognitive impairment, as indicated by their low BIMS scores, making them unable to consent. The Administrator acknowledged that the incidents were reported to her by a registered nurse but were not reported to the State Agency. She stated that the incidents were not recognized as sexual abuse, believed there was no harm, and considered the behavior consensual based on staff input, despite the residents' inability to consent. The Administrator could not provide a rationale for determining consent and did not know which staff member observed the incidents. This failure to report the allegations as required by facility policy and regulatory requirements constitutes the deficiency.