Failure to Timely Report Alleged Abuse and Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported immediately, but not later than two hours after the allegation was made, to the Administrator and the New York State Department of Health, as required by state law. Three separate incidents involving a resident engaging in sexually inappropriate behavior with two other residents, both of whom lacked capacity to consent, were not reported to the appropriate authorities. In each case, staff intervened and separated the residents, but the incidents were not reported to the state agency or law enforcement, and in one instance, the Administrator was not notified until more than two weeks after the event. The facility's own policy required immediate reporting of any suspected abuse to the Supervisor/Administrator and mandated that the DON notify the Department of Health and law enforcement within two hours. Despite this, documentation showed that staff and supervisors were aware of the incidents, completed incident reports, and conducted internal assessments, but did not notify external authorities. The rationale provided by facility leadership was that there was no pain, injury, or mental anguish noted, and they could not confirm any sexual contact, leading them to determine the incidents were not reportable. Interviews with staff and administration confirmed that the incidents were not reported as required. The Administrator and DON both acknowledged delays in notification and a lack of reporting to the state and law enforcement. All residents involved were determined to lack capacity to consent to sexual behaviors, and the facility's failure to report these incidents constituted Immediate Jeopardy and Substandard Quality of Care, placing all residents at risk.
Removal Plan
- Facility hall monitors were instated for all three shifts to ensure residents stayed out of other resident rooms
- All residents in the facility were assessed for aggression risk
- Resident #1 was placed on a 1:1 at all times
- All staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse
- Staff education was completed online, and multiple department facility staff working were interviewed and were able to demonstrate understanding of the education