Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required. Specifically, a resident with severe cognitive impairment and a history of dementia alleged that another resident touched her breast. This allegation was overheard by a CNA, who did not report the incident to the charge nurse, Administrator, or DON, despite having been trained to do so. The CNA admitted to overhearing the allegation one to two weeks prior but did not act, believing the resident was confused. The incident was not reported to the facility's abuse coordinator or to the state agency within the required timeframe. The deficiency was identified when a non-staff person relayed the resident's allegation to surveyors, prompting further investigation. Interviews confirmed that neither the Administrator nor the DON had been informed of the allegation until surveyor intervention. The facility's own policy required immediate reporting of abuse allegations, especially those involving serious bodily injury or abuse, within two hours. However, the required notifications and investigation were not initiated until the surveyors became involved. The residents involved both had severe cognitive impairment and were admitted to a secure unit due to elopement risk and dementia. The alleged perpetrator denied the incident, and the alleged victim was unable to provide specific details about when the event occurred or which staff were aware. The lack of timely reporting and investigation meant that no interventions were initiated to protect the resident or prevent further abuse until after the surveyor's discovery.