Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of potential non-consensual sexual abuse involving two residents to the proper authorities and state agency within the required timeframes. According to the facility's own policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. In this case, a resident was observed entering another resident's room without consent, and there were reports from both staff and other residents of similar behavior. Despite these observations and reports, management was only notified for a possible room change, and there was no immediate notification to authorities or the resident's representative. Documentation in the electronic medical record showed that the resident who entered the room had a history of altered mental status and was redirected multiple times from female residents' rooms. Staff, including an LPN, reported concerns about the resident's sexually inappropriate behavior to the Administrator and DON, but were instructed to follow administrative directives rather than escalate the matter to law enforcement or ensure a thorough evaluation of the potentially affected resident. The resident's representative was not formally notified of the incident, and the facility did not complete a timely or thorough investigation, as evidenced by incomplete documentation of a head-to-toe skin check and lack of interviews with other potentially affected residents. Interviews with staff and the resident's representative revealed that law enforcement and the Ombudsman were not notified promptly, and the Medical Director was also not informed of the potential abuse. The facility administration failed to ensure that all required parties were notified, did not conduct comprehensive resident interviews or assessments to rule out further harm, and did not document or communicate the incident as required by policy and regulation. The deficiency was identified as Immediate Jeopardy due to the failure to report and investigate the allegation of sexual abuse in a timely and appropriate manner.