Failure to Report Alleged Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse for one resident who was admitted with multiple diagnoses, including a left femur fracture, anxiety disorder, depression, anemia, and cerebral infarction. The resident was assessed as cognitively intact. On a specific date, nursing notes documented that the resident reported believing she was gang raped by night staff. Despite this serious allegation, there was no evidence that the incident was reported to the state agency as required. During the survey, facility staff interviews revealed that the process for handling abuse allegations included immediate reporting to supervisors and, if necessary, to external authorities. Multiple staff members, including CNAs and the ADON, confirmed awareness of the resident's allegation and described the internal investigation process. However, documentation showed that the facility did not self-report the incident to the state agency within the required timeframe, and the Director of Nursing was unable to produce any self-reports or investigations for the relevant period until prompted by surveyors. Policy review indicated that the facility's procedures required immediate reporting of abuse allegations to the Administrator, State Survey Agency, and other authorities, with specific timelines depending on the severity of the event. Despite these policies, the facility did not follow through with external reporting for the resident's allegation of sexual abuse, and internal documentation was incomplete or missing. Staff interviews further confirmed that the required notifications to state authorities were not made.