Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an alleged or suspected incident of sexual abuse to the State Agency within the required two-hour timeframe. Resident #1, who had Parkinson’s disease with dyskinesia, dementia, generalized anxiety disorder, and major depressive disorder, was severely cognitively impaired per the annual MDS and care plan, which noted impaired cognitive function and the need for cueing, reorientation, supervision, and observation for signs of distress. Resident #2, who also had severe cognitive impairment and diagnoses including dementia, anxiety disorder, irritability and anger, and unspecified psychosis, had a care plan revised after the incident to reflect a history of physical and sexual aggression toward females related to anger, dementia, history of harm to others, and poor impulse control. On the day of the incident, an OLTC Incident and Accident Report documented that at 12:05 PM the facility recorded the discovery of Resident #1 standing in Resident #2’s room, with both residents fully clothed. After Resident #1 was taken back to their room and perineal care was performed, blood was noted in Resident #1’s brief, and redness was observed in the vaginal area upon assessment by the charge nurse and nurse manager. Assessment of Resident #2 revealed a scant amount of dried blood on the first and second digits of the left hand. CNA #1 reported finding Resident #1 in Resident #2’s room between 10:30 AM and 10:40 AM, and CNA #2 reported noticing blood in Resident #1’s brief at approximately 11:00 AM, at which time LPN #5 was notified. LPN #5 stated that around 11:00 AM she was informed by CNA #2 about the blood in Resident #1’s brief and that she observed a small amount of blood herself, then contacted the Director of Admissions and Marketing around 11:30 AM. The Director of Admissions and Marketing reported being notified at 11:30 AM and assessing Resident #1, then reporting the situation to the DON and the Administrator at around 12:00 PM. The DON stated she was informed by the Administrator around noon that there had been an incident between the two residents. The Administrator confirmed she was notified around 12:00 PM and acknowledged that, although facility policy and regulatory requirements mandated reporting allegations or suspicions of abuse to the State Agency within two hours, the report to OLTC was submitted at approximately 3:50 PM, close to four hours after discovery, because she wanted to gather more information and facts before reporting. This delay constituted the failure to ensure timely reporting of alleged or suspected sexual abuse as required by policy and regulation.
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