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F0609
D

Failure to Report Sexual Abuse Allegation to Law Enforcement

Mansfield, Ohio Survey Completed on 05-13-2025

Penalty

Fine: $63,450
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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 report an allegation of sexual abuse involving a resident to local law enforcement, as required by policy and regulation. A resident with intact cognition and a history of Hodgkin's lymphoma and malnutrition reported to an LPN that a CNA had groped her breast and inserted his finger into her vaginal area during incontinence care. The LPN notified the Administrator, who then informed the DON. The resident, her family, and her physician were notified, and the resident declined to be sent to the hospital. The CNA in question was suspended and later terminated, but the incident was not reported to local law enforcement or other agencies, despite the facility's policy requiring such action when a crime is suspected. The investigation revealed that the resident was upset and requested no male caregivers following the incident. The facility's documentation showed that the resident and her family declined police involvement, citing embarrassment and a desire for privacy. However, the facility did not offer alternative arrangements for the resident to speak with law enforcement in a more private setting. Interviews with staff and other residents indicated that some residents had negative impressions of the CNA, and another resident described an uncomfortable experience with the same CNA, though she had not previously reported it. The facility's policy clearly stated that suspicions of a crime, including sexual abuse, must be reported to local police immediately, in addition to notifying the state health department and the resident's family and physician. Despite this, the facility did not notify law enforcement, relying instead on the resident's and family's wishes. The omission of this required reporting constituted a failure to follow established protocols for handling allegations of abuse, potentially affecting the safety and well-being of all residents in the facility.

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