Failure to Identify and Report Sexual Abuse Incident
Penalty
Summary
The facility failed to identify, investigate, and report an incident of sexual abuse involving a resident. According to the facility's abuse prevention policy, all alleged abuse, including sexual abuse, must be reported to the appropriate authorities. Record review revealed that a resident was subjected to forced observation of masturbation by their roommate, which caused the resident to feel uncomfortable and scared. Documentation showed that the roommate was found rummaging through the resident's personal belongings and then masturbating beside the resident's bed. Despite being aware of the incident, the DON and Administrator confirmed that they did not recognize the event as sexual abuse and therefore did not investigate or report it to the State Survey Agency as required.