Failure to Timely Report Alleged Sexual Abuse to Required Authorities
Penalty
Summary
The facility failed to ensure that an allegation of sexual abuse involving a resident was reported to the State Agency, law enforcement, and Adult Protective Services (APS) within the required timeframe. The resident involved had a complex medical history, including traumatic subdural hemorrhage, acute kidney failure, and moderate cognitive impairment, as indicated by a BIMS score of 11. Documentation showed that the resident's mental status fluctuated, with periods of alertness, confusion, and agitation. A grievance was filed by the resident's daughter regarding a male CNA providing care, which led to interventions such as assigning only female caregivers and initiating trauma-informed care measures. Despite the grievance and subsequent care plan changes indicating a possible sexual assault, the facility did not document the allegation of sexual abuse in the clinical record. The self-report to the State Agency was made several days after the initial grievance, and there was no evidence that law enforcement or APS were notified as required by both facility policy and state law. Interviews with staff, including CNAs, RNs, the DON, and the Administrator, revealed inconsistent understanding and application of reporting timeframes and requirements. The Administrator and DON acknowledged the allegation but chose not to report to law enforcement or APS, citing the vagueness of the allegation and advice from the ombudsman. Facility policy and federal regulations require immediate reporting of abuse allegations to appropriate authorities, including law enforcement and APS, especially when there is reasonable suspicion of a crime against a resident. The facility's failure to report the allegation in a timely manner, and to all required agencies, constituted a deficiency in protecting residents from potential abuse. The deficiency was further compounded by the lack of documentation and the decision to rely on subjective judgment rather than established reporting protocols.