Failure to Report Sexual Abuse Allegation to Law Enforcement and APS
Penalty
Summary
The facility failed to correctly develop and implement its abuse policy following an allegation of sexual abuse involving a resident with moderate cognitive impairment and a complex medical history, including traumatic subdural hemorrhage and acute kidney failure. The resident was unable to answer orientation questions and appeared confused at the time of the incident. A grievance was filed regarding a male CNA providing care, and the care plan was updated to specify female caregivers only, referencing the resident's history of trauma from sexual assault. However, there was no documentation in the clinical record of an explicit allegation of sexual abuse. Despite the facility submitting a self-report to the State Agency regarding an allegation of staff-to-resident sexual abuse, there was no evidence that law enforcement or Adult Protective Services (APS) were notified as required. Staff interviews revealed an understanding that abuse allegations should be reported immediately or within 24 hours, and that reporting to law enforcement and APS was necessary. However, both the DON and the Administrator confirmed that they did not report the incident to law enforcement or APS, with the Administrator stating that she believed reporting to these agencies was optional and that the ombudsman advised against contacting APS. Review of facility policy and state and federal regulations confirmed that all alleged or suspected abuse must be promptly reported to appropriate authorities, including law enforcement and APS. The facility's failure to report the allegation to these agencies was inconsistent with both its own policy and regulatory requirements. The deficiency was identified through clinical record review, interviews, and policy review, and was documented in the State Agency complaint tracking system.