Failure to Timely Report Resident-to-Resident Sexual Altercation to State Agency
Penalty
Summary
The facility failed to timely notify the State Agency of a resident-to-resident sexual altercation involving a cognitively impaired, wheelchair-dependent resident (R28). Record review showed that on a Saturday afternoon, R28 was inappropriately sexually touched by a cognitively impaired, wheelchair-dependent male resident. Nursing notes documented the incident in the clinical record, but the Director of Nursing (DON) and Social Worker were not notified until the following Monday. Facility policies in the Abuse-Risk Management Folder and the Compliance with Reporting Allegations of Abuse/Neglect/Exploitation procedure require that appropriate agencies, including the State Agency and Adult Protective Agency, be notified immediately and no later than 24 hours after discovery of an allegation of abuse. In an interview, the DON confirmed that the incident occurred on Saturday and acknowledged it should have been reported to Licensing and Certification at that time, but the State Agency was not notified until she became aware of the incident on Monday.
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