Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to timely report multiple allegations of abuse, neglect, and theft involving a resident with severe cognitive impairment and a history of mental health issues. Over a period of several weeks, the resident and other female residents reported feeling unsafe due to another resident's sexually inappropriate behavior, harassment, and theft. Specific incidents included unwanted letters, verbal advances, and being followed to common areas, as well as reports of items being stolen. Despite these ongoing concerns, the facility did not report the allegations to the State Agency within the required timeframe. Documentation and interviews revealed that staff, including the DON and social services, were aware of the inappropriate behaviors and the residents' discomfort. The DON acknowledged receiving complaints and conducting internal investigations but chose not to report the incidents, citing a belief that the resident involved was capable of consenting to the interactions. However, there was no clear determination of the resident's capacity to consent, and the facility's own assessments indicated the resident was at risk for abuse due to cognitive impairment and other vulnerabilities. The facility's policy required immediate reporting of all alleged violations, including abuse and neglect, to the administrator, state agency, and other authorities. Despite this, the allegations were not reported until well after the incidents occurred, and some staff members were unaware of all the events. The delay in reporting and lack of timely action failed to provide the required protections for the residents involved.