Failure to Timely Report Alleged Sexual Abuse Between Roommates
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the appropriate authorities within the required time frame. Resident 1, who had cerebral palsy, a right elbow contracture, and severe cognitive impairment per a recent MDS, was allegedly subjected to sexual abuse by a cognitively intact roommate, Resident 2, who had a diagnosis of unspecified dementia. According to IDT notes, two CNAs entered the shared room for a recheck and found Resident 2 sitting at the end of Resident 1’s bed with his pants down, his back to the door, one hand under Resident 1’s gown, and his other hand on his own genital area. In a separate interview, CNA 1 reported that on the evening prior, he had entered the room after providing evening care and found Resident 2 sitting on Resident 1’s bed with his briefs pulled down, his right hand on his own genitals, and his left hand on Resident 1’s hip; when CNA 1 pulled back the covers, Resident 1’s penis was exposed, and Resident 1 became tearful and stated, “Get him away from me.” CNA 1 stated he reported this to the Nurse Supervisor on duty that evening. The Administrator confirmed in interview that the abuse allegation occurred on 2/8/26 and that the report to the California Department of Public Health (CDPH) was not made until 2/9/26 at 4:12 p.m. The facility’s policy and procedure on Abuse, Neglect, Exploitation, and Misappropriation, revised 10/12/23, requires all mandated reporters to report incidents or alleged violations of abuse not later than two hours after the allegation is made, including a written report to the local Department of Public Health Licensing and Certification office. The Administrator also stated that her expectation was that the initial incident report of the abuse allegation be sent to CDPH and other enforcement agencies within two hours of the allegation. The delay between the time the allegation was made and the time it was reported to CDPH constituted a failure to follow the facility’s abuse reporting policy and the federal requirement for immediate reporting of alleged abuse.
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