Failure to Report Resident’s Allegation of Sexually Inappropriate Staff Conduct
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) as required under F609. A cognitively intact resident with diagnoses including amyotrophic lateral sclerosis (ALS) and major depressive disorder, who was dependent for ADLs, reported that a CNA made an inappropriate sexual gesture while providing personal care. The resident stated that the CNA thrust his pelvic area against a gray stool in the room in a way the resident found offensive and felt was mocking his sexual orientation as a gay man, which made him feel angry. The resident reported this incident to the Director of Staff Development (DSD), whom he identified as a mandated reporter. The DSD confirmed in interview that the resident had reported the CNA’s inappropriate gesture and that the resident felt the CNA was mocking his lifestyle because he is gay. The DSD acknowledged she is a mandated reporter and that the allegation should have been reported for the resident’s safety and to ensure a proper investigation, but she did not report it. The DON stated that the DSD should have reported the allegation immediately, that the allegation was a form of abuse, and that it should have been reported so a proper investigation could be conducted and the resident could be monitored for emotional distress. Review of the facility’s Abuse Prevention and Prohibition Program policy indicated that allegations of abuse must be reported immediately, but no later than two hours after forming a suspicion, to the state survey agency, law enforcement, and the Ombudsman, 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.