Failure to Timely Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to timely report an alleged incident of sexual abuse between two cognitively impaired residents. The incident involved a female resident who wandered into a male resident's room in the memory care unit, where staff observed the male resident's hand near the female resident's private area while she was seated on his bed. There was uncertainty among staff regarding whether the residents were clothed, and the initial staff member who witnessed the event did not immediately report it to management, believing it did not require further attention. The incident occurred in the evening, but the report to the Indiana Department of Health (IDOH) was not made until the following day, exceeding the facility's policy requirement to report within two hours. Multiple staff members, including the Social Services Director (SSD), Director of Nursing (DON), and Administrator, were involved in the communication and investigation process. The SSD was notified by the DON via secure message and subsequently contacted the nurse who witnessed the incident. The SSD advised the nurse to contact the Administrator but did not provide further instructions or come to the facility that night. The Administrator and DON discussed the situation, but the information exchanged was vague, and the DON did not directly contact the nurse who witnessed the event. The SSD and Administrator handled the investigation and notifications, but there were delays in notifying the residents' representatives and law enforcement. Facility policy required immediate reporting of abuse allegations to the Executive Director and the IDOH within two hours, as well as notification to law enforcement and Adult Protective Services. Despite these requirements, the incident was not reported to the appropriate authorities in a timely manner. The delay in reporting and lack of immediate action by staff and management contributed to the deficiency cited in the report.