Failure to Report Resident-to-Resident Sexual Abuse Allegation to State Agency
Penalty
Summary
The facility failed to ensure an allegation of resident-to-resident sexual abuse was submitted to the appropriate state agency as required by its abuse, neglect, and exploitation policy. A resident with cognitive communication deficit, anxiety disorder, mood disorder, and a moderately impaired BIMS score of 10 reported to the Social Worker and Nurse Manager that another resident had entered her room, discussed buying her a drink and having food in his room, and then, after she went to his room, grabbed her breast. She further reported that he later came into her room again, playing pornography on his phone and touched her breast a second time. A nursing progress note documented that a head-to-toe assessment was completed, that the resident denied pain and declined a room change, and that the Medical Director, CNP, power of attorney, Administrator, regional staff, and DON were notified, as well as the county sheriff’s office. The alleged perpetrator was a resident with intact cognition (BIMS 15), no upper or lower extremity impairments, and a care plan documenting sexually inappropriate behaviors, including perceiving relationships with peers as more sexually oriented than they actually were and touching behaviors. His care plan included interventions such as limiting at-risk situations, redirecting him from entering other residents’ rooms without permission, and providing 1:1 care, which had been initiated prior to the survey. During interview, the DON acknowledged that there was a self-reported incident (SRI) for the sexual abuse allegation but confirmed it was not submitted to the proper state agency. The Administrator and DON stated that a complete investigation had been done but not submitted because the Administrator became distracted while entering the report and failed to hit the submit button, later deciding, after consulting corporate staff, not to submit it since it would be considered late. The facility’s written policy required reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified time frames, which did not occur in this case.
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.