Failure to Immediately Report and Investigate Allegation of Sexual Abuse
Penalty
Summary
Facility staff failed to ensure a resident was free from abuse by not immediately reporting, investigating, and addressing an allegation of sexual abuse. The resident, who had heart failure, intact cognition, and required extensive assistance with ADLs including personal care and toileting, reported that about five days prior a CNA cleaned her perineal area and touched her inappropriately in her vagina. The resident stated she reported this to the social worker, but nothing was done. The resident’s MDS showed she was dependent on staff for lower body dressing, toileting, and footwear, and required maximal or partial assistance for other ADLs, indicating reliance on staff for intimate care. The Social Services Worker acknowledged that the resident reported the allegation of abuse to her on the evening of 1/26/2026 and that she was aware of the facility’s abuse reporting policy, but she did not report the allegation to the Administrator, DON, or other leadership, did not complete an SOC 341, and did not notify police or the Ombudsman. The Administrator confirmed she had not been informed of the allegation and stated it should have been reported the day it occurred. The DSD reported that several days earlier the Ombudsman had informed her that the resident said she had been touched inappropriately by a staff member, but the DSD did not seek further details and assumed the resident was referring to back rubs, and no investigation was initiated and the CNA was not suspended. The DON stated he was not made aware of the allegation when it was reported and that the failure to report prevented implementation of immediate protective interventions. Review of the facility’s abuse policy showed that all abuse allegations must be reported immediately (within two hours) to the administrator and appropriate agencies, and that any employee accused of abuse is to be placed on leave with no resident contact until the investigation is complete, which did not occur in this case.
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