Failure to Report Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to identify and report allegations of abuse involving three residents, as required by federal regulations. One resident, who was cognitively intact and recovering from a left ankle fracture, reported that a male resident entered her room uninvited, placed his hand under her blanket, and attempted to move his hand up her thigh. She resisted and called for help, after which the male resident moved to her roommate's bed and repeated similar behavior. The roommate, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to answer questions about the incident. Both incidents were witnessed or reported to staff, and the nurse practitioner and guardians were notified, but the events were not reported to the State Agency as required. The male resident involved had a documented history of sexually inappropriate behavior toward both staff and other residents, including multiple incidents of inappropriate touching and comments in the weeks leading up to the event. Progress notes indicated ongoing behavioral issues, and the care plan included interventions to monitor and redirect the resident away from female residents. Despite these documented behaviors and the specific incident involving two female residents, the facility did not submit a report of the abuse allegation to the State Agency. Interviews with staff confirmed that the incident was reported internally to the Nursing Home Administrator, who stated that she did not report the event to the State Agency because she believed there was no physical contact. However, both the resident and a registered nurse confirmed that inappropriate touching had occurred. The facility's own abuse prevention policy required investigation and reporting of all abuse allegations within required timeframes, but this was not followed in these cases.