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F0609
D

Failure to Timely Report Alleged Sexual Abuse

Tazewell, Tennessee Survey Completed on 11-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to report an allegation of sexual abuse involving a resident with severe cognitive impairment within the required two-hour timeframe. The facility's policy mandates immediate reporting of all alleged violations, including abuse, to the Administrator, state agency, and other authorities within two hours if the allegation involves abuse or results in serious bodily injury. Despite this, multiple staff members, including a Family Nurse Practitioner, Certified Nurse Assistant, Registered Nurse, Social Worker, and RN MDS Coordinator, became aware of the resident's and her family's concerns about possible sexual abuse but did not report the allegation to administration or authorities as required. The resident in question was admitted with diagnoses including dementia, heart failure, and a mixed receptive-expressive language disorder, and was assessed as having severe cognitive impairment. The concern was initially raised by the resident's daughter, who reported that her mother believed someone had touched her inappropriately. Staff interviews revealed that the daughter's concerns were communicated to several staff members, who either did not act on the information or assumed others would report it. The Social Worker and other staff did not notify administration, citing the family's belief that the incident may have been imagined and their stated desire not to file a complaint. The failure to report persisted until the local police department notified the facility that an allegation had been filed with Adult Protective Services by the resident's daughter, at which point the facility initiated an investigation. The Administrator confirmed that staff had prior knowledge of the allegation before being notified by the police, indicating a clear delay in reporting as required by facility policy and federal regulations.

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