Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual and verbal abuse to the State Agency in a timely manner for five residents. Multiple staff members, including an LPN, CNA, and Social Worker, witnessed or were informed of incidents where a male resident, who was cognitively intact but had a history of boundary issues, kissed two female residents with cognitive impairments who could not legally consent. These incidents were reported internally to the facility's administrator, who was made aware of the potential abuse but chose not to report the allegations to the State Agency, contrary to facility policy and regulatory requirements. The administrator assessed the residents himself and determined that the contact was welcome, despite staff statements and documentation indicating otherwise. The residents involved included individuals with significant cognitive impairments and histories of trauma, making them particularly vulnerable. One female resident had a BIMS score indicating severe cognitive impairment, while another had moderate impairment and a history of trauma. Both were unable to consent to the contact. Staff notes and interviews revealed that the incidents were not welcomed by the residents, and in at least one case, a resident was visibly in shock and did not respond to the incident. Another resident, who was cognitively intact, reported feeling uncomfortable and changed her dining habits to avoid the male resident after a separate incident involving inappropriate verbal and physical behavior. Despite multiple staff members recognizing these incidents as potential abuse and expressing concern that failure to report could lead to further incidents, the administrator did not initiate the required reports to the State Agency. Facility policy required immediate reporting of any abuse allegations, including those involving residents who could not consent, but no incident or accident reports were found for the affected residents. The lack of timely reporting resulted in the potential for incomplete investigations and further unreported abuse.