Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made. This deficiency was identified for two residents who reported allegations of inappropriate and potentially abusive behavior by a certified nursing assistant. The facility did not document evidence that these allegations were reported to local law enforcement or the New York State Department of Health as required by regulation. One resident, with a history of multiple sclerosis, protein-calorie malnutrition, and pseudobulbar affect, reported that a male certified nursing assistant made inappropriate comments about their shaved vaginal area and applied cream to their buttocks despite the resident's request to self-apply. The resident delayed reporting the incident due to embarrassment, and the family member subsequently informed facility leadership. Despite the resident and family expressing concerns about safety, the facility leadership determined within two hours that there was no evidence of abuse and did not report the incident to authorities. The facility's policy did not include guidance on reporting to law enforcement, and the staff involved did not consider the incident to be sexual abuse. A second resident, with diagnoses including type 2 diabetes, depression, and anxiety disorder, reported that the same certified nursing assistant rubbed their genital area in a manner that made them feel violated. The resident was visibly upset and reported the incident to another staff member, who escalated it to a supervisor. However, the facility did not document any report to authorities or conduct a formal investigation, as leadership did not believe the incident constituted abuse. Interviews with facility leadership and the medical director revealed a lack of awareness and appropriate response to the allegations, and no physical or psychosocial assessments were completed for the residents involved.