Failure to Timely Report Allegations of Abuse Due to Resident's Psychiatric History
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, exploitation, and mistreatment were reported immediately, but no later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, the facility did not report an allegation of sexual abuse made by a resident with a history of bipolar disorder and schizoaffective disorder. The resident, who had a legal guardian, made repeated statements to nursing staff over several months indicating she believed she was being raped by an unknown male, sometimes describing the perpetrator as transforming into other people or using technology to harm her. Nursing progress notes documented multiple instances where the resident expressed fears and allegations of sexual abuse, including claims of being raped by an unknown male, being impregnated, and requests for help. Staff interviews revealed that these allegations were consistently reported up the chain to the DON and Administrator, but were not reported to the state. Staff and leadership attributed the resident's statements to her psychiatric diagnoses, describing them as delusions or hallucinations, and determined internally that the allegations were unsubstantiated. Despite the facility's policy requiring immediate reporting of all alleged or suspected abuse to the state agency, the DON and Administrators decided not to report the allegations, citing the resident's history of delusions and the lack of evidence or named individuals matching the allegations. The facility's records confirmed that no self-reports were made to the state regarding these allegations during the relevant period.