Failure to Report Allegations of Sexual Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report allegations of sexual abuse involving residents with cognitive impairments. In one incident, a CNA entered a resident's room and observed two residents, both partially undressed, in a compromising position. The CNA reported the situation to a nurse, and the administrator later conducted an internal investigation. Despite the facility's policy requiring immediate reporting of all abuse allegations to state authorities, the administrator decided not to report the incident, reasoning that no intercourse had occurred. The administrator later acknowledged that the incident should have been reported, as any allegation is required to be reported and then investigated. The residents involved had significant cognitive impairments. One resident had diagnoses including dementia, sleep disorder, general anxiety disorder, and severe cognitive impairment as documented in the Minimum Data Set (MDS). The other resident involved in the incident had moderate cognitive impairment and similar diagnoses. The facility's own policy mandates reporting all alleged violations to the administrator, state agency, and other required agencies within specified timeframes, but there was no documentation that the Illinois Department of Public Health was contacted regarding the initial allegation or the results of the investigation. A review of prior incidents revealed another episode involving two cognitively impaired residents found together in a private room. Staff separated the residents and reported the situation to the nurse, who then informed the previous administrator. However, the administrator instructed staff not to document the incident in the residents' charts, and there was no evidence of an abuse investigation or reporting to authorities. Interviews with staff and review of facility records confirmed that no abuse investigations had been conducted in the last six months, despite these incidents.