F0607

E

Failure to Timely Report and Investigate Alleged Sexual Abuse

Kingsville, Texas Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and follow its written abuse, neglect, and exploitation policies when a hospice resident with severe cognitive impairment allegedly reported sexual abuse by another resident. The resident was an elderly male on hospice care with COPD, type 2 diabetes, unspecified dementia, depression, anxiety, and a history of stroke, and his admission MDS showed a BIMS score of 3, indicating severe cognitive impairment. On the evening in question, his responsible party (RP) was feeding him when another male resident walked by; the hospice resident became fearful and told the RP that the man who had been at the door had gone into his room and put a finger in his rectum. The RP reported this to facility staff, and the resident was moved to another hall and closer to the nurse’s station that same evening, but the contemporaneous nursing documentation only reflected a room move due to the hall being too loud and did not document the allegation or the reason for the hospice nurse’s visit.

Multiple interviews and records showed that the allegation of sexual abuse was known to several individuals on the date it was made, but the facility did not report it to the state agency within two hours as required by its policy, nor did it initiate an immediate, documented investigation at that time. The hospice records documented that the hospice nurse was dispatched for a PRN visit specifically because of a reported sexual assault, that an outcry had been made by the patient to his family, and that the hospice nurse assessed the resident’s anus for trauma with a facility LVN present. The hospice nurse’s narrative stated she had been briefed that the resident reported another resident put a finger in his buttocks, and she documented that the facility administrator and hospice would follow up per protocol. Hospice staff, including the hospice director and hospice social worker, reported that they informed the administrator on the evening of the allegation, and that the administrator stated she was aware of the allegation and was starting the investigation process. However, the administrator later stated she did not consider what she was told by the RP to be an actual allegation of abuse and therefore did not report it at that time.

Facility staff interviews revealed inconsistent knowledge and communication about the allegation and the reason for the room change. Several CNAs stated they were told by an LVN or charge nurse that the resident was moved because another resident had touched him or that something had happened between the two residents, while the social worker and one ADON reported they were only told the move was due to noise and anxiety and were unaware of an abuse allegation until days later. The DON stated she was informed by the administrator on the night of the room change only that the RP had concerns about the other resident being loud and causing anxiety, and she did not come to the facility that night. The ADON on call reported she was not notified of the allegation on the date it occurred, despite facility expectations that allegations be reported immediately to administration and on-call leadership. The facility’s abuse policy required immediate investigation and reporting of all alleged violations to the administrator and state agency within two hours when abuse was involved, but there was no timely report to the state survey agency and no contemporaneous, complete documentation of an investigation into the sexual abuse allegation until two days later, when the administrator self-reported after being informed again of the allegation by hospice and internal staff.