F0609

D

Failure to Timely Report Alleged Sexual Abuse to Required Agencies

Fowler, California Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a cognitively intact resident to required external agencies, as mandated by federal and state regulations and the facility’s own abuse policies. A resident with diagnoses including COPD, DM2 with neuropathy, asthma, epilepsy, bipolar disorder, major depressive disorder, PTSD, and age-related cognitive decline, but with an MDS BIMS score of 15 indicating no cognitive impairment, reported that a CNA showed her a nude video of another CNA. The resident described the video as showing the CNA naked in a bathroom with only a small towel over his privates or his nude behind as he was getting into or out of the shower. The resident stated she was shocked that an employee would show her such a video and reported the incident to staff, after which she was interviewed by the Administrator and identified the CNA who allegedly showed her the video.

Multiple staff interviews and policy reviews confirmed that the conduct described by the resident met the facility’s definition of potential abuse, specifically sexual abuse, which includes forced observation of pornography. The LVN who first received the allegation from the resident stated that staff are required to protect residents from abuse, ensure dignity and respect, and report abuse allegations right away. The LVN reported the allegation to the Infection Preventionist and then to the Administrator, who served as the abuse coordinator, but did not complete the SOC 341 form herself. The LVN acknowledged that showing a resident a video of a naked person was not acceptable, could be considered a form of abuse, and that the alleged sexual incident should have been reported to the required government agencies.

The Infection Preventionist, Director of Staff Development, and DON each confirmed that all facility staff are mandated reporters and that the facility’s Abuse, Neglect and Exploitation and Abuse Prevention and Prohibition Program policies require reporting all alleged violations involving abuse to the Administrator, state agency, adult protective services, ombudsman, and law enforcement within specified timeframes, including within two hours for abuse allegations. The IP stated that the SOC 341 should have been completed and the allegation reported within two hours. The DSD stated that the SOC 341 should have been completed and that the abuse coordinator was responsible for reporting to law enforcement and the ombudsman. The DON acknowledged that the facility did not report the allegation because the resident did not report distress after seeing the video, despite recognizing that it was inappropriate for staff to show a nude video to a resident and that failure to report abuse allegations could jeopardize the facility’s license. A subsequent interview with the ombudsman confirmed that he was not aware of the allegation and had no SOC 341 on file. The facility’s job descriptions for the Administrator, CNA, charge nurse, DON, and IP all required reporting allegations of abuse and compliance with abuse reporting policies, yet the allegation involving this resident was not reported to the required government agencies as mandated.

The report also documents that the CNA accused of showing the video denied the allegation but acknowledged that it would be considered abuse to show a resident a naked video and that SOC 341 should be completed and submitted immediately to ensure prompt facility response. The CNA noted that delayed reporting of alleged abuse could result in continued occurrences. Despite this, and despite the facility’s written policies outlining mandated reporting duties, timeframes, and penalties for failure to report, the allegation involving the resident and the nude video was not reported to the ombudsman, state survey agency, or local law enforcement. The DON explicitly stated that the facility did not maintain mandated reporting for this incident because they did not report the allegation, confirming the core deficiency of failure to timely report suspected abuse as required.

The facility’s policies and job descriptions further emphasized that facility staff are mandated reporters under the Elder Justice Act and state regulations, that the facility will not impede reporting, and that failure to report within mandated timeframes may result in civil money penalties, exclusion from federal health care programs, and disciplinary action up to and including termination. The policies also defined sexual abuse to include forced observation of pornography and required telephone and written reports to the ombudsman or local law enforcement within specified timeframes for incidents including emotional or psychological abuse. Despite these clear written requirements and staff awareness that the alleged conduct could constitute abuse, the facility did not complete the SOC 341 or submit required reports for the resident’s allegation, and the ombudsman confirmed no report was received. This sequence of inaction by facility leadership and staff in response to a reported potential sexual abuse incident constitutes the documented deficiency.