F0609

D

Failure to Timely Report Alleged Sexual Abuse to State Authorities

San Antonio, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a cognitively impaired resident to the State Survey Agency (HHSC) and other required authorities. The resident was an elderly female with vascular dementia, moderate cognitive impairment (BIMS score of 11/15), memory deficits following a stroke, left-sided weakness, and generalized anxiety disorder. She was dependent or required substantial/maximal assistance for most ADLs, including transfers, toileting, and bathing, and was frequently incontinent. Her care plan identified memory problems, difficulty communicating needs due to cognitive impairment, and risk for emotional distress and behaviors, with interventions focused on reassurance and monitoring for emotional issues.

The events leading to the deficiency began when the resident reported that a male staff member had kissed and touched her. In a documented interview dated the day after the incident, when asked if she had ever been treated in a rough, inappropriate, or unkind manner, the resident responded, "Yes, some man kissed me and touched me." Video recordings from the resident’s room showed a CNA seated close to the resident’s bed with his arm under the blankets near her chest, leaning over and audibly kissing her near the head, and later standing at the bedside holding her hand, kissing her near the mouth, and then on the mouth while caressing her face. The resident verbally responded to the CNA, including thanking him after a kiss and engaging in conversation, but the videos documented repeated kissing and physical contact of an intimate nature while the resident was in bed and dependent on care.

An anonymous source reported that the resident had stated the CNA kissed her, which prompted review of the room camera and the sending of the video to the Administrator and DON via email. The email with the video was sent the day after the incident, and the DON acknowledged receipt and stated they would address the issue. In subsequent interviews with surveyors, the Administrator and DON stated they did not consider the incident reportable because they believed there was no allegation by the resident or her family and characterized the conduct as unprofessional rather than abuse or exploitation. They also referenced a previous unsubstantiated allegation of inappropriate touching by the same CNA with another resident. Despite the resident’s documented statement that a man had kissed and touched her, the video evidence of kissing and intimate contact, and the facility’s own abuse policy requiring prompt reporting of all alleged or suspected violations, the facility did not report the allegation and incident to HHSC as required, resulting in the cited deficiency for failure to timely report suspected abuse.

Additional interviews further illustrated conflicting accounts and the facility’s determination not to treat the incident as a reportable allegation. In an interview with surveyors, the resident later denied being kissed on the mouth and stated she was told by administration that the CNA was only trying to console her because she was sad, adding that she did not feel threatened and was surprised anyone would want to kiss her at her age. The DON reiterated to surveyors that there was no allegation from the resident or family member and that the video showed only unprofessional conduct. In a telephone interview, the CNA stated the resident had expressed loneliness and suicidal thoughts, asked for a hug, and that he hugged and kissed her on the cheek, describing the interaction as mutual and denying kissing her on the lips or being inappropriate. Despite these varying descriptions, the documented resident statement that a man kissed and touched her, combined with the video evidence and the facility’s policy defining and requiring reporting of all alleged or suspected abuse, formed the basis for the surveyors’ finding that the facility failed to ensure the alleged violation was reported immediately, but not later than two hours after the allegation was made.