F0609

D

Failure to Timely Report Injury of Unknown Origin and Alleged Sexual Abuse

Jeffersonville, Georgia Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The facility failed to follow its Abuse, Neglect and Exploitation policy requiring timely reporting of alleged violations to the administrator, state agency, and other authorities. The policy specified that allegations involving abuse or serious bodily injury must be reported immediately, but no later than two hours after the allegation, and other events within 24 hours. A resident with anoxic brain damage, seizure disorder, psychosis, anxiety disorder, memory problems, and severely impaired decision-making reported that a man had touched her private area. Hospice staff, including a CNA and Social Worker, observed bruises on the resident’s back and shoulders and were informed by the resident that someone had touched her inappropriately. These concerns were communicated to facility staff, including a CMA, LPNs, and the DON.

The hospice agency notified the resident’s family that the resident had bruises and had reported inappropriate touching, and the family later observed bruises that facility staff could not explain. Hospice CNA DD reported the bruises and allegation to the Hospice Administrator and an LPN at the facility. The Hospice Social Worker reported the bruises and allegation to the facility CMA and DON. The CMA assessed the bruises and reported them to an LPN but did not report the allegation to the Administrator. The LPN reported the bruising to the DON and Administrator. The DON acknowledged being notified in January of the bruises and the allegation of inappropriate touching and stated she discussed these with the Administrator and a Corporate Consultant, who advised that the incidents should not be reported. As a result, the injury of unknown origin and the allegation of sexual abuse were not reported to the State Survey Agency as required by the facility’s policy.