Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to implement its policies and procedures to ensure timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of sexual abuse. A resident with moderate cognitive impairment and multiple medical diagnoses reported that another resident, who also had cognitive impairment, entered her room and tickled her foot without consent. The incident made the resident feel uncomfortable and she believed the other resident wanted to have sex with her. The resident did not report the incident immediately but informed a Certified Nursing Assistant (CNA) the following morning, who then reported it up the chain of command to a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and finally to the facility Administrator (ADM), who is the abuse coordinator. Despite the report being escalated through appropriate staff, the ADM did not consider the incident to be sexual in nature and therefore did not report the allegation to the State Survey Agency (SSA) as required by Section 1150B of the Act and the facility's own policy. The facility's policy mandates immediate reporting of suspected abuse, neglect, or exploitation to local, state, and federal agencies, including the SSA, but this was not followed in this case. The staff members involved, including the CNA, LVN, and RN, recognized the incident as potentially sexual abuse and reported it accordingly, but the final decision by the ADM resulted in a failure to report. The deficiency was identified through interviews and record reviews, which confirmed that the facility did not report the allegation of sexual abuse within the required timeframe. This lapse was due to the ADM's judgment that the incident was not sexual in nature, despite the resident's statements and the opinions of other staff members. The facility's failure to report the incident as required delayed the investigation of the suspicion of sexual abuse.