Failure to Timely Report Allegation of Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents, both of whom had severe cognitive impairment and lacked the capacity to consent. One resident was found kissing and attempting to climb into the bed of another resident who was dependent on staff for personal care and mobility. The incident was documented in progress notes but was not reported to the facility Administrator or the California Department of Public Health (CDPH) as required by facility policy and state regulations. Interviews and record reviews revealed that nursing staff, including a registered nurse and a licensed vocational nurse, were aware of the incident but did not follow the abuse reporting policy. The Director of Nursing acknowledged being informed of the event but did not instruct staff to report it to CDPH. The facility's policy clearly defined non-consensual sexual contact as sexual abuse and mandated immediate reporting to both the Administrator and the state agency within two hours of the allegation. Despite multiple staff members, including a certified nursing assistant, recognizing their responsibility as mandated reporters, the incident was not escalated appropriately. The lack of timely reporting resulted in a delay in investigation by the CDPH and left the affected resident at risk for further abuse. Documentation confirmed that neither resident could provide consent, and the event met the facility's definition of sexual abuse, yet the required notifications were not made.