Failure to Report Resident’s Allegation of Sexual Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of possible abuse was immediately reported to management and within two hours to the State Survey Agency, as required by its Abuse Investigation and Reporting policy. The policy, revised July 2017, required that all alleged violations involving abuse, neglect, exploitation, mistreatment, or injuries of unknown origin be promptly reported to local, state, and federal agencies and that abuse or serious bodily injury be reported no later than two hours after the allegation. Despite this, the allegation made by one resident was not reported to the Department of Health and Senior Services (DHSS), and there was no documentation that facility administration was notified. The resident involved had been admitted with diagnoses including paranoid schizophrenia and had a quarterly MDS indicating moderate cognitive impairment, delusions, and verbal behavioral symptoms directed at others. On the night in question, an LPN documented that the resident returned from the emergency room and was yelling and screaming, stating that the "N word" next door was putting his penis in the resident’s buttocks. The LPN further documented that the resident used a hand gesture to describe the alleged sexual act. The LPN noted that the other resident was asleep and believed at the time that this resident was unable to get out of bed unassisted, and explained to the resident that the allegation was impossible and that racial slurs were not tolerated. The progress note did not include any notifications to administration or external authorities regarding this allegation of possible abuse. In a subsequent interview, the LPN stated that he/she did not think the allegation should be reported because of the resident’s diagnosis of paranoid schizophrenia and believed it was a hallucination, and therefore did not notify the Administrator. Other staff interviews showed inconsistent understanding of reporting requirements: some CNAs and nurses stated that abuse allegations should be reported to the charge nurse, DON, Administrator, and to the state within two hours, while one CNA believed the state should be notified within 24 hours, and one LPN was unsure whether the allegation should be reported to the state. The ADON and Administrator both stated that abuse allegations should be taken seriously, reported to administration immediately, and reported to the state within two hours, and acknowledged that this resident’s allegation should have been treated as possible abuse and reported and investigated, which did not occur.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.