Failure to Timely Report Alleged Sexual Abuse Incident
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 24 hours after the allegation was made. Specifically, the facility did not report an incident involving two residents, where one was found massaging the breast of another after removing her adult brief, to local law enforcement or the State Survey Agency as required. The incident was observed by a CNA, who found the two residents alone in the dining room, with one resident's bra around her waist and her brief missing, while the other resident was holding the brief. The CNA intervened, ensured the resident was dressed, and notified the nurse, who then informed the Administrator. Record reviews revealed that there was no documentation of the sexual incident in the progress notes, nor was there any documentation of notification to the doctor or the designated representative. The Administrator conducted what he described as a "soft investigation" and determined that the incident was not reportable, despite the circumstances and the facility's own abuse and neglect policy, which requires immediate reporting of such allegations. The Administrator stated that he could not assume anything had happened between the residents because there were no witnesses, even though the CNA's account and the video evidence indicated otherwise. The residents involved had significant cognitive impairments and care plans that identified risks such as impaired mobility, self-care deficits, and potential for aggressive behaviors. The facility's failure to report the incident as required by policy and regulation resulted in a deficiency, as it did not follow established procedures for reporting suspected abuse, neglect, or exploitation to the appropriate authorities within the mandated timeframe.