Failure to Immediately Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse involving a resident with severe cognitive impairment. Staff observed one resident touching another resident's breast in a common area. Although the incident was witnessed and initially reported by a CNA to an RN, the RN did not immediately notify the Administrator, DON, or other required personnel. The incident occurred after dinner, but the Administrator and DON were not informed until over two hours later, despite facility policy requiring immediate reporting of abuse allegations. Interviews revealed that staff were aware of the requirement to report abuse immediately to supervisory staff, including the Administrator and DON, and had the means to do so after hours. However, there was a breakdown in communication, as the initial report was not escalated promptly. The facility's policy, which mandates reporting of all alleged violations to the Administrator within two hours, was not followed in this case, resulting in a delay in the notification and investigation of the alleged abuse.