Failure to Timely Report Witnessed Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to immediately report a witnessed incident of sexual abuse between residents to the state agency and other required authorities. Facility policy on abuse required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation was made, to the administrator or designee and to officials including the state survey agency and adult protective services. The Nursing Home Guidelines (Purple Book) further specified that resident-to-resident sexual abuse/assault incidents must be reported to the DSHS hotline, logged within five days, and that police or 911 be called. Resident 1, who had dementia and anxiety disorder and was assessed as moderately cognitively impaired, was admitted on a specified date. Resident 2, who had dementia, aphasia, and a cognitive communication deficit and was assessed as severely cognitively impaired, was also admitted on a specified date. On 02/02/2026 at 11:45 AM, an incident report documented that Resident 1 was touched inappropriately by Resident 2. A progress note at 12:45 PM the same day showed that a CNA found Resident 1 in Resident 2’s room being touched on the breasts by Resident 2 and notified the nurse, who then wrote an alert report to inform managers of the incident. However, the state agency report showed the incident was not reported until 02/03/2026 at 10:42 AM, outside the required two-hour timeframe. Incident investigation documentation showed the nurse did not immediately report the inappropriate touching to the administrator, state agency, or police, despite being a mandated reporter. During interviews, multiple CNAs, LPNs, and an RN described that abuse should be reported promptly to supervisors and the DSHS hotline, and the Administrator and DNS later stated they only became aware of the incident the following morning while reviewing progress notes and that the incident should have been reported immediately to leadership, DSHS, and the police within two hours.
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