F0609

D

Failure to Timely Report Allegations of Physical and Sexual Abuse

Hermitage, Missouri Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that all allegations of abuse were immediately reported to facility management and to the state agency within required timeframes. Facility policy required any employee or volunteer who became aware of abuse, neglect, exploitation, or misappropriation to immediately report to the Administrator, and required the Administrator or designee to report allegations of abuse or serious bodily injury to the state agency within two hours, including during nights and weekends. Despite this, staff did not promptly report an allegation of physical abuse involving one resident and repeated allegations of sexual abuse involving another resident, and one of the allegations was not reported to the Department of Health and Senior Services (DHSS) at all.

For the first resident, who had vascular dementia with agitation and resided on a special care unit, the Administrator learned from the resident’s responsible party that the resident had bruises on the hands and arms and that an unnamed staff member had reported that a CNA had abused the resident. The Administrator’s subsequent interview with a CNA revealed that on a morning shift the CNA had entered the special care unit and observed another CNA in the resident’s room holding the resident’s forearms while the resident resisted and verbally objected to being put back to bed. The CNA reported hearing the other CNA repeatedly yell at the resident to get back in bed while the resident yelled that they did not want to go back to bed. The CNA stated that the two were struggling, that the resident tried to get loose while the CNA continued to hold and push the resident toward the bed, and that the resident later wanted to call the police and was difficult to calm. The CNA reported that shortly after the incident, they called the nurses’ station and told an LPN to come assess the resident’s arms, informed the LPN that the CNA had tried to hold the resident’s arms down and that the arms appeared bruised, and later that same day told other aides and the DON at the nurses’ station that the CNA had bruised the resident’s arms while trying to force the resident back into bed. The DON later documented scattered bruising on both upper extremities in various stages of healing and notified the physician. However, the allegation of abuse was not reported to DHSS until three days after the incident, and the LPN denied being informed of any incident involving the resident and the CNA.

For the second resident, who had dementia, depression, anxiety disorder, delusional disorder, and paranoid personality disorder with severe cognitive impairment and dependence on staff for multiple ADLs, multiple staff and a hospice RN were aware that the resident had repeatedly stated that a man was raping them. The hospice RN reported that over approximately two weeks the resident said, "Don’t let that man in here. He’s raped me," and on a couple of occasions was tearful and said a man came in and raped them. The hospice RN stated that they "blew it off," believed they may have told an LPN or the DON, and did not know they had to report the allegation because the resident had dementia. A CNA recalled the resident stating at the nurses’ station that they had been raped, with the charge nurse present, and reported that the resident repeated the rape allegation a few days later during care; the CNA said they told an LPN or another nurse, who responded that the resident was confused. Other CNAs reported hearing that the resident had claimed rape multiple times, some stating they had reported the allegation to a charge nurse over two months earlier. Despite these repeated allegations and staff awareness, the facility did not self-report the rape allegation to DHSS until it was documented later as an allegation of sexual assault, and the DON stated that no one had informed them of any rape allegation, even though the DON considered such comments to be an allegation of abuse. Staff interviews showed inconsistent understanding and application of the requirement to immediately report all abuse allegations, including those made by confused residents, to facility leadership and to DHSS within two hours.