F0609

D

Failure to Immediately Report Resident-on-Resident Sexual Abuse Allegation to State Agency

Del Rio, Texas Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report an allegation of abuse to the State Agency (HHSC) as required by regulation and facility policy. A cognitively intact female resident with spastic hemiplegic cerebral palsy, generalized anxiety disorder, and spina bifida with hydrocephalus reported to facility staff, in the presence of her family member, that a male resident had been sexually inappropriate with her on multiple occasions. The family member brought the resident to the Administrator (who is the abuse coordinator) and the DON, and the resident described that the male resident had touched her breasts and genital area over clothing, kissed her, and engaged in repeated intimate contact over several days. The resident also stated there were times she did not verbally consent and times she told him no. This information was documented on a grievance form and in a typed interview on the same day.

The Administrator and DON interviewed both residents and initiated an internal investigation. The female resident’s account included that she had invited the male resident into her room, discussed sexual content on television, and allowed or encouraged intimate touching, while also reporting that he had made a move on her that she did not like and that she cried and did not ask for it. The male resident denied any sexual contact, stating he only waved to her, had given her a necklace and some food, and did not enter her room for sexual purposes. The facility also interviewed nearby residents, who denied witnessing inappropriate behavior, and placed the male resident on a behavior monitoring log. Despite the conflicting accounts and the initial allegation of sexual abuse, the Administrator later stated that the facility did not submit a self-report to HHSC because their investigation concluded that what the female resident was claiming was not true.

Throughout this period, the resident’s cognitive status was documented as intact, with BIMS scores of 13–15 and orientation in all spheres, and she was considered capable of making her own decisions. She had a documented history of behavioral issues, including crying out, yelling at family and staff, and seeking attention from multiple male figures, as well as a care plan problem related to ineffective coping and sexualized or attention-seeking behaviors. Therapy and counseling notes showed that she later told her therapist and the occupational therapist that the relationship with the male resident was consensual, that she liked the contact, and that she had lied to her family member because she did not want them to know. However, the facility’s own abuse policy defined an “alleged violation” as any reported situation that could indicate abuse and required reporting all alleged violations to the Administrator, state agency, APS, and other required agencies immediately but not later than 2 hours when abuse was involved. The Administrator, as abuse coordinator, acknowledged that no state report was made, and the DON was unsure if a state report had been completed, establishing that the facility failed to ensure the allegation was reported to HHSC within the required 2-hour timeframe.

The deficiency is further supported by the facility’s written policies on Abuse, Neglect and Exploitation and on Incidents and Accidents, which require that alleged abuse be treated as an incident requiring an incident report and prompt external reporting. The Administrator stated that the alleged incident was initially treated as abuse but that, during the two hours they had to report, the resident changed her story and said she had lied, and on that basis the facility chose not to submit a report to the state. Despite this, the policy did not condition reporting on the outcome of the internal investigation or the perceived credibility of the allegation. Surveyor interviews and record review confirmed that no immediate report to HHSC was made for this allegation involving possible sexual abuse between residents, resulting in noncompliance with the requirement to report all alleged violations of abuse immediately, but not later than 2 hours, to the State Agency.