Failure to Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the State agency as required by policy. According to witness statements and interviews, a resident with intact cognition reported that another resident, who had moderate cognitive impairment and a diagnosis of Alzheimer's disease, attempted to kiss and grab his genitalia while sitting on his bed. The incident was immediately reported by the resident to staff, and the Director of Nursing (DON) documented the event, moved the reporting resident to a new room, and obtained statements from both residents. The accused resident denied the inappropriate contact and did not recall the incident. Despite the report and documentation of the alleged abuse, the DON and Administrator decided not to file a self-reported incident (SRI) with the State agency, reasoning that no actual contact occurred. Review of facility records confirmed that the incident was not reported to the State agency, contrary to the facility's policy, which requires all reports of abuse to be promptly reported and investigated. This deficiency was identified during a complaint investigation and was based on record review, resident and staff interviews, and review of facility policies.