Failure to Immediately Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of abuse involving one resident was immediately reported to facility administration and appropriate external authorities as required by policy and federal regulations. The resident, who had heart failure, required extensive assistance with ADLs, and had intact cognition, reported that about five days prior a CNA had 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 social services worker confirmed that the resident reported an allegation of abuse to her on the evening of 1/26/2026, acknowledged knowing the abuse reporting policy and the requirement to immediately report such allegations to administration, but did not notify the Administrator, DON, or other leadership, did not complete the SOC 341, and did not contact law enforcement or the Ombudsman as required by facility protocol. The Administrator stated she had not been informed of the allegation and confirmed that such conduct would be considered abuse and should have been reported the day it was reported to staff. The DSD reported that several days earlier, during an Ombudsman visit, the resident had also reported being touched inappropriately by a staff member, but the DSD did not seek further details and assumed the resident was referring to back rubs the resident usually requested; no investigation was initiated and the alleged perpetrator 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 the facility from implementing immediate protective interventions. Review of the facility’s abuse reporting and investigation policy showed that all reports of resident abuse were to be immediately reported to the administrator and appropriate agencies within two hours, and that any employee accused of abuse was to be placed on leave with no resident contact until the investigation was complete, which did not occur in this case.
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