F0609

G

Failure to Recognize and Timely Report Suspected Physical and Sexual Abuse

Galena, Kansas Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and immediately report signs of possible physical and sexual abuse, including injuries of unknown origin and vaginal bleeding, for one resident. On the night of 03/21, two CNAs observed significant bruising on the resident’s right leg while providing care with the resident’s durable power of attorney (DPOA) and primary caregiver present. They reported the bruising to the charge nurse, who assessed the bruises as small, linear, and appearing old, accepted the DPOA’s explanation that they were from therapy or wheelchair positioning, and did not initiate an investigation, document the findings, or report the injury to administrative staff or external authorities. Later that night, at approximately 04:20 AM, the same CNA observed bright red vaginal bleeding and a possible lesion or clotted blood on the labia, reported this to the same nurse, and was instructed to clean the resident and apply antifungal cream for a presumed yeast infection without the nurse assessing the area or documenting the change in condition.

At 06:00 AM, the night nurse verbally passed on that there had been vaginal bleeding, suspected to be from itching or a yeast infection, to the oncoming nurses and recommended contacting the provider, but no one identified these findings as potential abuse or an injury of unknown origin requiring immediate reporting. Around 08:00 AM, another CNA providing peri care with the DPOA present noted dried blood and small cuts or lacerations around the vaginal area and promptly notified a nurse, who confirmed dried blood, bruising on the hip, and a labial laceration but attributed the findings to itching and did not suspect abuse. This nurse reported the findings only to the resident’s charge nurse and did not notify administrative staff, law enforcement, or the state survey agency. During this period, multiple CNAs reported feeling uncomfortable and unsettled by the DPOA’s constant presence during intimate care, his refusal to leave the room, his habit of closing the door, and his jittery and anxious behavior, and at least two CNAs documented that the resident made distressing statements such as asking why they let “that man” do that and “Son, why would you do this to me?”, but these concerns were either not documented as reported or, when reported, were not acted upon.

In the early afternoon, around 02:22 PM, two nurses jointly assessed the resident and identified extensive injuries, including a large bruise on the right hip and leg resembling the shape of a hand, dark maroon/purple bruising on the labia and into the vagina, a small laceration at the posterior vaginal opening, a shearing-type injury on the labia, scattered petechiae, bruising on the lower abdomen, and ongoing vaginal bleeding. The resident displayed increased anxiety during this assessment, repeatedly saying “Oh God,” and was unable to state what had happened. Only at this point did the nurses recognize the situation as potential sexual abuse and notify an administrative nurse, who then notified the administrator. Law enforcement was contacted later that afternoon, and the state survey agency was notified by email that evening, nearly 20 hours after the initial identification of an injury of unknown origin and several hours after administrative staff became aware of suspected abuse. Throughout the delay in recognition and reporting, the resident remained in the room with the alleged perpetrator, who had been present during all cares over the previous 23 hours and left the building frantically after the injuries were more fully recognized. The facility’s own abuse policy required immediate reporting, but not later than two hours after an allegation involving abuse or resulting in serious bodily injury, which was not followed in this case.