Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to fully implement its abuse prohibition procedures in response to an alleged incident of sexual abuse involving a resident and the resident's visitor. According to the facility's abuse policy, all allegations of abuse must be reported immediately to the Director of Nursing (DON) or, in their absence, to the Nurse Supervisor on duty, with further immediate notification to the Nursing Home Administrator (NHA) and DON, including after-hours contact if necessary. The policy also requires prompt reporting to the State Survey Agency and law enforcement within specified timeframes. However, staff witness statements revealed that the initial report of the incident, which involved hearing inappropriate noises from the resident's room, was not promptly escalated according to policy. The LPN who received the report from a nurse aide did not immediately notify the RN Supervisor, and the RN Supervisor was not informed until two days after the alleged incident. There was no documentation in the resident's clinical record regarding the alleged abuse, and neither the NHA, DON, attending physician, nor the resident's responsible party were notified at the time of the incident. The facility did not initiate an internal investigation until two days after the alleged event, and notification to the State Survey Agency was not made within the required two-hour timeframe for allegations of sexual abuse. Staff interviews confirmed that the facility's abuse prohibition procedures were not followed, resulting in delayed identification, notification, and investigation of the alleged abuse. The deficiency was cited under multiple Pennsylvania Codes related to management, resident rights, responsibility of licensee, nursing services, and resident care policies.