Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to the state survey agency (CDPH) within the required federal time frame and to submit the results of the investigation within five working days. One resident with dementia and Alzheimer’s disease, who was assessed as severely cognitively impaired and dependent or needing assistance with most ADLs, was the alleged victim. According to the SBAR documentation, a CNA observed the cognitively impaired roommate kneeling by the resident’s bed and touching the resident’s genital area while the resident was lying in bed. The CNA intervened, separated the residents, and reported the incident to an RN, who then notified the physician, DON, and Administrator. The roommate alleged to have committed the touching also had dementia and polyneuropathies and was documented as severely cognitively impaired, requiring assistance with transfers, dressing, hygiene, and other ADLs. SBAR documentation for this resident indicated that when interviewed by the RN after the incident, the resident did not remember what had occurred. Another cognitively intact resident later reported that, on a separate occasion, he had witnessed the same roommate lowering the alleged victim’s brief and touching the victim’s buttock in their shared room and that he had reported this to an unidentified staff member. The report does not identify any injuries but characterizes the incident as inappropriate sexual touching of a resident who lacked capacity to consent. Interviews with facility leadership and staff showed that the incident was reported to local law enforcement and the ombudsman, but not to CDPH. The DON stated she was informed of the incident and confirmed that it was reported to the police and ombudsman only. The RN reported that the Administrator instructed her not to call CDPH because both residents had dementia. The Administrator stated that, based on his interpretation of AFL 24-09 and the absence of injury, he believed the incident did not need to be reported to CDPH. Review of the facility’s Abuse Investigation and Reporting policy showed it required reporting all alleged violations of abuse to the state licensing/certification agency and also referenced AFL 24-09 for resident-on-resident abuse involving residents with dementia. Both the Administrator and DON later acknowledged, after reviewing the CMS SOM, that the allegation of sexual abuse involving a resident without capacity to consent should have been reported to CDPH within two hours and that a five-day written investigation report was also required, but this did not occur.
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