Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to mandated entities within the required two-hour timeframe. The incident involved a resident with diagnoses including myoneural disorder, toxic encephalopathy, dysphagia, ataxia, and PTSD, who was cognitively intact according to a recent BIMS assessment. The resident reported to police that an unknown male x-ray technician had touched her breast during a medical procedure at the facility, and that she had informed a nurse at the time, who responded that the alleged perpetrator had left the building. Despite the resident's report to facility staff, there was no evidence in the facility's self-report incident logs or the State Agency database that the allegation was reported as required. Police initiated an investigation after the resident's hospital discharge, contacting facility staff for information about the alleged incident and requesting video footage, which was ultimately unavailable. Interviews with staff, including the ADON, Administrator, and DON, revealed that while staff were aware of the two-hour reporting requirement and the need to ensure resident safety, none of the key personnel recalled being informed of the abuse allegation or conducting an internal investigation related to the resident's claim. Facility policy required immediate reporting of abuse allegations to supervisors, the Administrator, the State Survey Agency, and Adult Protective Services. However, the review of records and staff interviews confirmed that the required notifications were not made following the resident's report. The deficiency was identified through interviews, clinical record review, and examination of facility policies and procedures.