Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse of residents were reported immediately, but not later than 2 hours after the allegation was made, as required. Specifically, a resident with severe cognitive impairment and a history of reliving past trauma alleged sexual abuse to her Mental Health Habilitator (HAB). The HAB promptly informed the facility's Assistant Director of Nursing (ADON) about the allegation. Despite this, the facility did not report the allegation to law enforcement or the State Agency (SA) within the required 2-hour timeframe. The resident involved had multiple diagnoses, including Bipolar Disorder, Dementia, Down Syndrome, and severe cognitive impairment, and was dependent on staff for personal care. Her care plan noted a history of reliving trauma related to past sexual abuse and included interventions to provide consistency and avoid triggering discussions. On the day of the incident, the resident told her HAB that she had been raped, but was unable to provide specific details. The HAB, concerned due to the lack of prior similar behaviors, reported the allegation to the facility. The ADON and Administrator (ADM) interviewed the resident, who gave inconsistent responses and was unable to provide clear information about the alleged perpetrator or timeframe. The facility staff referenced the resident's care plan history and concluded the allegation was likely related to past trauma. Despite facility policy requiring immediate reporting of all abuse allegations to the Administrator, state agency, and law enforcement, the ADM and DON decided not to report the incident, believing it was a recurrence of past trauma rather than a new event. Interviews with staff confirmed that the expectation was to report all allegations, but in this case, the required notifications were not made. The facility's failure to report the allegation within the mandated timeframe constituted a deficiency in abuse reporting procedures.