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F0609
D

Failure to Timely Report Allegation of Sexual Abuse

Palmyra, Missouri Survey Completed on 06-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its policy regarding the timely reporting of an allegation of sexual abuse involving a resident with paraplegia and moderate cognitive impairment. The resident reported to a CNA that a staff member had engaged in sexually inappropriate behavior, including stroking the resident's hair and handling women's underwear in a suggestive manner. The CNA reported the allegation to an LPN, who then informed an RN, but the information was not escalated to the Director of Nursing (DON) or the Administrator as required by facility policy. Despite multiple staff members being made aware of the allegation, including the CNA, LPN, and RN, none of them reported the incident to the DON or Administrator until four days after the initial report. The RN, who was the nursing supervisor at the time, did not believe the allegation and failed to notify the appropriate authorities or follow the established reporting protocol. The DON and Assistant DON were also not informed in a timely manner, and the Administrator only became aware of the situation after several days had passed. When the Administrator was finally informed, she did not notify the state agency within the required two-hour window, instead reporting the incident several hours later. The facility's policy clearly states that allegations of abuse must be reported to the state agency immediately, but no later than two hours after the allegation is made. The failure to promptly report the allegation and initiate an investigation as required by policy and regulation constitutes a deficiency in the facility's abuse reporting procedures.

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