Failure to Timely Report and Document Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to immediately report allegations of resident-to-resident sexual abuse to the Administrator and the State Agency, as required by policy. On two separate occasions, a cognitively impaired resident was found in a compromising situation with another resident who was cognitively intact but had intellectual disabilities. In one incident, a resident was found on another resident's bed with the other resident exposing his erect penis, and the first resident had saliva on his face and mouth. In another incident later the same day, a resident was found with feces and blood on his shirt and brief, while his roommate was in the same room performing self-gratification of his rectum, with feces and blood on his hands. The affected resident indicated to police that his roommate had manipulated both his own and the affected resident's penis in a sexual manner, despite being told to stop. Staff members observed and reported these incidents to various supervisors and managers, but the information was not promptly or accurately relayed to the Administrator or the State Agency. The facility's own policy required immediate notification of the Administrator and/or DON, as well as reporting to the state/certification agency, Ombudsman, and Adult Protective Services as applicable. However, the Administrator was not made aware of the potential sexual nature of the incidents until the following day, after the resident's family had been anonymously informed and contacted the police. The initial self-reported incident submitted to the State Agency did not identify the allegation as sexual abuse, and there was no indication that the incident involving the other resident was reported at all. The clinical records for the involved residents lacked documentation of the events, and skin assessments performed did not address the genitals or rectal areas, despite the nature of the allegations. The facility's failure to follow its abuse reporting policy resulted in a delay in protecting residents from further abuse and in notifying the appropriate authorities. The deficiency was identified through interviews, record reviews, and review of staff statements, which revealed inconsistencies and gaps in the reporting and documentation of the incidents.