Failure to Report Alleged Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by its own policy. A resident with diagnoses including paranoid schizophrenia, generalized anxiety disorder, and hallucinations, and who was assessed as cognitively impaired, was hospitalized following a fall. During her hospital stay, she alleged that she had been raped multiple times by another resident approximately six weeks prior. The hospital notified law enforcement, the resident's family, and a facility RN of the allegation. However, there was no evidence that the facility reported this allegation to the State Survey Agency. Interviews with facility staff confirmed that the Director of Nursing and Administrator were made aware of the allegation via text message, and the matter was discussed in a staff meeting. The staff decided not to report the allegation to the State Survey Agency, believing it was not a true reportable event. This decision was made despite the facility's policy requiring immediate reporting of all abuse allegations, and no initial report was submitted to the State Survey Agency regarding the resident's rape allegation.