F0609

D

Failure to Accurately Report Alleged Sexual Abuse Incident

Nanticoke, Pennsylvania Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to accurately and completely report and document an alleged incident of sexual abuse to the State Survey Agency and the Area Agency on Aging, as required by its own abuse policies. The facility’s Abuse Protection policy required reporting occurrences of abuse, neglect, misappropriation, and suspicions of a crime to the State Survey Agency, Department of Aging, and local law enforcement, and specified that events involving serious bodily injury, including sexual abuse, must be reported within two hours of forming the suspicion. A related policy on Identifying Sexual Abuse and Capacity to Consent required immediate protective measures, immediate reporting to appropriate authorities, a thorough investigation including assessment of capacity to consent, and thorough documentation and reporting of the investigation results. These policies formed the basis for the expectations the facility did not meet.

Resident 1, who had dementia and a BIMS score of 7 indicating severe cognitive impairment, and Resident 2, who had a cerebral infarction and a BIMS score of 14 indicating intact cognition, were involved in the incident. According to the facility’s abuse investigation report, a nurse aide (Employee 3) observed Resident 1 on Resident 2’s bed at approximately 1:15 AM, with Resident 2 seated in his wheelchair at the bedside and Resident 1 unclothed. The facility’s report stated that both residents indicated they were talking and concluded there was no evidence of penetration. However, written witness statements from Employee 3 and Employee 4 documented additional details that were not reflected in the facility’s report, including that Resident 1 had been last seen in her own chair around 12:50 AM, was later found unclothed in Resident 2’s bed, and that Resident 2 was observed touching Resident 1’s vaginal area while her legs were open.

The witness statements further documented that after the incident Resident 1 complained of vaginal pain or discomfort and was observed checking herself in the bathroom. Despite these eyewitness accounts, the information submitted by the facility to the State Survey Agency and the Area Agency on Aging did not identify that staff directly observed Resident 2 touching Resident 1’s vaginal area and did not report Resident 1’s complaint of vaginal pain immediately following the incident. Instead, the facility reported that Resident 1 exhibited no signs or symptoms of distress, which was inconsistent with the written statements of Employees 3 and 4. During interviews, the Nursing Home Administrator acknowledged that the facility did not report all observed findings because both residents stated they were just talking, and it was confirmed that the facility did not follow its established abuse policy and procedures for reporting abuse or factually report all relevant information obtained during the investigation.