Delayed Reporting of Suspected Sexual Abuse Incident
Penalty
Summary
The facility failed to timely report an incident of potential sexual abuse involving two residents. One resident, with a history of bipolar disorder, schizophrenia, and anxiety and with intact cognition, was found in her room performing oral sex on another resident. The other resident involved had schizoaffective disorder, bipolar disorder, hallucinations, and impaired cognition. The incident was discovered by staff during the night shift, and both residents were separated at that time. Documentation in the medical records and staff witness statements confirmed the timing and nature of the incident. Despite the facility's policy requiring immediate reporting of abuse allegations to the State Agency within two hours, and no later than 24 hours for all alleged violations, there was a significant delay in reporting. The incident occurred before midnight, but the Assistant Director of Nursing (ADON) was not notified until after midnight via text, and the Director of Nursing (DON) was not informed until later that morning. The Self-Reported Incident (SRI) and formal investigation were not initiated until approximately 33.5 hours after the incident, exceeding the facility's required reporting timeframe.