Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to report an allegation of inappropriate touching between two residents within the required 24-hour timeframe. Specifically, one resident with severe cognitive impairment and a history of sexually inappropriate behavior was observed by two other residents placing his hand between the legs, over the clothing, of another resident who was also severely cognitively impaired. The incident was witnessed by two cognitively intact residents, one of whom immediately reported it to an LVN present at the nurses' station. The LVN responded by removing the alleged perpetrator from the dining room and returning him to his room. Despite being informed of the incident, the LVN did not document the event in the progress notes, did not assess for injury beyond a brief check, and failed to report the allegation to the facility Administrator or DON as required by facility policy and federal regulations. The LVN stated she was aware of the reporting requirements and had previously received in-service training on abuse, neglect, and exploitation (ANE) reporting, but could not explain why she did not report the incident. The Administrator and DON both confirmed they were unaware of the incident until informed by surveyors during the investigation. Record reviews confirmed that both residents involved had significant cognitive impairments and behavioral care plans addressing inappropriate behaviors. The facility's policy required all allegations of abuse, neglect, exploitation, or mistreatment to be reported within 24 hours to the Administrator and to the appropriate state authorities. The failure to report this incident as required resulted in a deficiency, as it prevented timely investigation and appropriate follow-up as mandated by regulations.