Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of potential abuse involving a female resident who had recently been discharged from the hospital for acute kidney injury and other chronic conditions. The resident reported that she awoke to find someone lying next to her in bed, who then pulled down her undergarment and left the room quietly. Despite this report, the facility did not identify the incident as potential abuse and did not notify the required external authorities, including the Office of Healthcare Assurance (OHCA), Adult Protective Services (APS), or the police. Interviews with facility staff revealed confusion and a lack of consensus regarding the reporting requirements for such incidents. The Social Services Coordinator stated that nursing was responsible for reporting to the state and social services to APS, but admitted she did not report the incident. The Assistant Director of Nursing (ADON) did not perceive the incident as abuse or a crime, and therefore did not notify authorities, believing the event could have been related to patient care. The ADON also indicated that the incident was not reported because there was no confirmation of abuse or sexual contact at the time. Further, the Administrator in training and the Chief Executive Officer both stated that the incident was handled as a grievance rather than a reportable event. They believed that since the initial investigation did not find evidence of abuse and the sexual allegation was raised after the resident left the facility, it was not their responsibility to report. The facility's own policy, however, required immediate reporting of suspected abuse or sexual assault to law enforcement and state agencies, which was not followed in this case.