Failure to Timely Report Suspected Sexual Abuse Incident
Penalty
Summary
The facility failed to submit an initial report to the State Survey Agency within the required two-hour timeframe following a suspected resident-to-resident sexual abuse incident involving two residents. According to the incident documentation, one resident was found in another resident's room by two staff members; the second resident was lying in bed with his brief undone while the first resident had her hand on his penis. The incident occurred at 1:30 a.m., but the report was not received by the State Survey Agency until over 21 hours later. Staff interviews revealed confusion regarding the reporting requirements, with one staff member incorrectly believing that only incidents involving serious bodily injury needed to be reported within two hours, and others could be reported within 24 hours.