Failure to Immediately Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of abuse to the Administrator, which delayed required reporting to the State Agency. Resident B, who had diagnoses including unspecified dementia with moderate cognitive impairment, major depressive disorder, and cognitive communication deficit, was observed on 3/22/26 by a Qualified Medication Aide (QMA 7) performing oral sex on Resident C in her room. QMA 7 saw Resident C standing in front of Resident B with his pants partially down, exposing his buttocks, while Resident B, seated in a recliner and leaning forward, was performing oral sex. QMA 7 instructed Resident C to leave the room, and he became angry but complied. QMA 7 then reported the incident to the charge nurse, and staff kept Resident C away from Resident B and other female residents. Resident C, who had diagnoses including unspecified dementia with severe cognitive impairment and delusional disorders, was later documented in an SBAR summary as having been observed receiving oral sex from a female resident, after which he was asked to leave the room and was closely monitored. When QMA 7 reported the initial observation to Registered Nurse (RN) 16, RN 16 did not report the allegation to anyone else at that time and only made a behavioral note, indicating she believed residents were allowed to have a sexual relationship. The Administrator later stated that the incident was not reported to the State Agency until the day after it occurred, because RN 16 did not notify the DON until the following morning, and the DON then notified the Administrator. This sequence of events conflicted with the facility’s Abuse Prevention Program policy, which required the person observing suspected abuse to immediately report it to the charge nurse, and the charge nurse to immediately report it to the Administrator, who must immediately notify the State Licensing and Certification Agency.
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