Failure to Report Resident’s Allegation of Sexual Abuse to Required Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident to CDPH, the police, and the local Ombudsman as required. The facility’s abuse prevention policy stated that staff must immediately report any suspicions of client abuse to the Administrator, and that all reality-based accusations must be immediately investigated and reported to officials in accordance with state law, including CDPH. The resident involved had schizoaffective disorder, bipolar type, and was conserved, with a documented history of hallucinations and delusions. However, the resident’s most recent BIMS score was 15/15, indicating intact memory, orientation, and judgment. On one occasion, a licensed nurse reported via internal communication that the resident stated people came into her room and “rape her” when she was not fully awake. This information was relayed to the Wellness and Recovery Director (WRD) and the Director of Nurses. The WRD documented in a Social Services Note that the resident told a nurse she felt a peer was coming into her room and having sex with her without her consent, and noted that the statement was similar to previous unverifiable accusations. The WRD and Administrator subsequently conducted an internal investigation after a team meeting where the allegation was discussed. An SOC 341 form later showed that the WRD had emailed the resident’s conservator’s office stating that a peer was having sex with the resident without her consent and that the facility had investigated the allegation. During interviews, the resident became visibly distressed and denied making the statements attributed to her, while the nurse involved denied that the resident had said she was raped and characterized the communication as related to the resident’s fixation on becoming pregnant. The Administrator acknowledged that, according to facility procedure, allegations of sexual abuse should trigger immediate steps to protect residents and notification of police, social services, CDPH, and the Ombudsman within two hours, and confirmed that this allegation was not reported to those authorities.
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