Failure to Timely Report Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual abuse to the state agency within the required 24-hour timeframe. This deficiency was identified through medical record reviews, facility self-reported incidents (SRIs), incident investigations, and interviews with residents and staff. In one instance, a resident with severe cognitive impairment and another resident with moderate cognitive impairment were observed in a sexually inappropriate situation. Staff separated the residents and documented the event, but the incident was not reported to administration or the state agency until several days later. The Director of Nursing (DON) confirmed that the staff did not immediately report the incident, and the SRI was filed four days after the event occurred. In another case, two residents were observed engaging in sexual activity in a public area of the facility, specifically the smoking porch, in the presence of other residents. Both residents were physically exposed, and other residents complained about the incident. Staff addressed the behavior with the involved residents, but the incident was not reported to the administration or the state agency as required. The DON later confirmed that the incident was not investigated promptly to determine if sexual abuse had occurred, and the facility did not immediately file an SRI. The facility's policy required all allegations of abuse to be reported within the required timeframes, but this was not followed. Interviews with staff, including an LPN and a CNA, confirmed that the incidents were observed and reported internally but not escalated to the appropriate administrative or regulatory authorities in a timely manner. The DON and Administrator acknowledged the delay in reporting and the lack of immediate investigation. The failure to report these incidents as required affected four residents reviewed for abuse, all of whom had varying degrees of cognitive and behavioral impairments.