Failure to Report Alleged Resident-to-Resident Sexual Abuse and Investigation Results
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse involving two residents to the State Agency, Ombudsman, and law enforcement, and failure to submit the results of the investigation to the State Agency within 5 working days as required by regulation and facility policy. One resident, identified as the alleged perpetrator, had diagnoses including dementia, history of traumatic brain injury, anxiety disorder, major depressive disorder, and cerebrovascular disease, and had a care plan noting behavior problems such as wandering, refusing care, eating other residents’ food, and being sexually inappropriate. This resident’s MDS showed a BIMS score of 15, indicating no cognitive impairment. The other resident, identified as the alleged victim, had schizoaffective disorder, dementia, bipolar disorder, obsessive compulsive behavior, anxiety disorder, and Alzheimer’s disease, with care plans documenting impaired cognition, hearing deficit, and neurocognitive disorder, and an MDS BIMS score of 0, indicating severe cognitive impairment. On the date of the alleged incident, a NP note documented that staff reported the alleged perpetrator had his hands inside the back of the pants of the alleged victim and that both residents were kissing. The note also documented that the alleged perpetrator was a registered sex offender and had a history of sexually explicit verbal behavior and difficulty with redirection. A later NP note, written after the DON reviewed camera footage, stated that the initial staff report was inaccurate and that the video showed the residents holding hands, with one occasion where the alleged perpetrator placed his hand on the alleged victim’s thigh. The clinical record for the alleged victim contained no documentation of the incident between the two residents on the date in question. Interviews with the ADON, DON, Administrator, and other staff confirmed that an allegation had been made that the alleged perpetrator placed his hands down a female resident’s pants, but the DON and Administrator could not identify which staff member reported it and did not know which female resident was involved, despite having reviewed video footage. The DON stated that the incident was discussed in an IDT meeting, that the video showed hand-holding and a hand on a thigh, and that the incident was considered a behavior and not abuse, leading to the decision not to report it to the State Agency. The Administrator stated that intent to cause harm would constitute abuse, and the DON stated it would only be considered abuse if the psychiatric provider said so. There was no evidence in the records or facility documentation that the allegation was reported to the State Agency, Ombudsman, or law enforcement, and no evidence that the results of any investigation were reported to the State Agency within 5 working days, despite facility policy requiring immediate reporting of suspected abuse and a follow-up investigation report within 5 business days.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.