Failure to Timely Report Allegations of Sexual Abuse and Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to timely report multiple allegations of inappropriate sexual behavior, including sexual abuse and public indecency, to the state agency and/or local law enforcement as required. In one instance, a resident with multiple medical conditions and moderate cognitive impairment accused a registered nurse of rape during an episode of agitation and altered mental status. The allegation was made in the presence of EMS staff and the nurse, but was not documented or reported to the state agency. The nurse stated he informed the unit manager, who denied receiving this information, and the Director of Nursing later confirmed the allegation was not reported. Another incident involved a cognitively intact resident who reported to social services that her roommate had touched her inappropriately. The social worker notified the DON and separated the roommates, but law enforcement was not contacted because the resident's daughter declined further action. Documentation did not show that the police were notified, despite the facility's policy requiring such reporting for sexual abuse allegations. Additional deficiencies were identified regarding a resident with cognitive and behavioral issues who repeatedly exposed himself and urinated in public areas, witnessed by other residents. Although some incidents were reported to police after complaints from other residents, there was inconsistent documentation and failure to report certain incidents to the state agency. Facility staff, including the administrator and social services supervisor, were at times unaware of incidents or failed to file required incident reports, despite being notified via internal communications. The facility's own abuse prohibition policy mandates reporting such allegations to both the administrator and state authorities, which was not consistently followed.