Failure to Timely Report Resident’s Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse to the Administrator and to the state licensing agency (DHSS) within the required two-hour timeframe, as required by facility policy. The facility’s abuse policy states that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately, and no later than two hours when abuse or serious bodily injury is alleged. Review of DHSS records showed the facility did not report the allegation in question. Multiple staff interviews confirmed their understanding that an allegation of a staff member asking a resident to suck their breast or play with them constitutes sexual abuse and must be reported to the state within two hours. The resident involved had diagnoses including metabolic encephalopathy (acute), restlessness and agitation, acute pain due to trauma, schizophrenia, generalized anxiety disorder, and impulse disorder. The admission MDS indicated the resident was cognitively intact but had physical and verbal behavioral symptoms directed toward others and other behavioral symptoms occurring one to three days in the lookback period. The resident’s care plan documented a history of cussing, yelling, agitation with staff and other residents, lying about staff behavior or other residents, using manipulative tactics to gain attention or avoid certain actions, hitting objects and threatening to hit staff or others, and taking medications for schizophrenia, anxiety, and impulse disorder. On the date of the incident, the DON documented that the resident came to the DON’s office in the morning and stated that a restorative nurse aide (RNA) was making the resident suck the aide’s breast and play with the aide, and that this had been happening “for a while.” The DON brought in a CMT as a witness and called the RNA into the office, then asked the resident to repeat the accusation; the resident quietly repeated the allegation without looking at anyone. The RNA stated the resident had just left the therapy room after urinating on the floor, became angry when told to change clothes, and had said they would get the RNA fired. The resident denied this statement. The DON did not report the allegation to the state, stating that whether such conduct would be abuse would depend on the circumstances and that, in this case, the resident was upset with the RNA. The Administrator later stated they were not informed that the resident had actually made the specific sexual abuse allegation and, when the note was read to them, agreed it should have been reported as sexual abuse. DHSS records confirmed no report of the allegation was made.
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