Delayed Reporting of Suspected Sexual Abuse Due to Resident Misidentification
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse involving two residents, one of whom was cognitively impaired, to the state agency as required. The incident occurred when a cognitively intact resident was found engaging in a sexual act with a cognitively impaired resident, with an allegation that a cigarette was offered in exchange for sex. The cognitively impaired resident had a care plan indicating vulnerability to abuse, neglect, or exploitation. Upon discovery, there was confusion among staff regarding the identity of the involved resident, leading to an initial interview with the wrong individual who was alert and oriented. The Director of Nursing (DON) did not realize the correct resident involved was cognitively impaired until later the following day, at which point the appropriate internal and external notifications were made, including contacting the police, case manager, and responsible party. The DON acknowledged that the report to the state agency was delayed due to the confusion over resident identity and confirmed that the incident should have been reported immediately as per facility policy. The facility's policy requires immediate internal reporting of suspected mistreatment of vulnerable adults.