Failure to Timely Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to investigate and report allegations of sexual abuse involving a resident in a timely manner, as required by policy and regulation. After a resident with reduced mobility, altered mental status, and hypertension was transferred to a hospital, the facility's social services director was contacted by a hospital social worker regarding abuse allegations. Despite being informed of the allegations, the facility had not initiated an investigation or reported the incident to the California Department of Public Health (CDPH), the Ombudsman, or local law enforcement within the required two-hour timeframe. The staff member accused of abuse was also not suspended immediately following the allegation. Interviews with facility staff, including the CNA, social services director, MDS coordinator, Director of Staffing Development, Director of Nursing, and Administrator, confirmed that the established protocol for abuse allegations—which includes immediate reporting, investigation, and suspension of the accused staff—was not followed. The facility's own policy mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made, and that employees accused of abuse are to be suspended pending investigation. These steps were not taken, resulting in a delay in both the investigation and required notifications.