Failure to Timely Report and Properly Classify Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of staff-to-resident sexual abuse to the state agency as required by policy. A resident with severe cognitive impairment, dementia, depression, and multiple medical conditions, who required extensive assistance of two staff for mobility and transfers, alleged that a male CNA attempted to put his genitalia in her mouth. The resident identified the alleged perpetrator by name and physical description, which matched a male CNA on duty. The social worker designee and the human resources director interviewed the resident the same morning, confirmed the description, and contacted the Administrator by phone while in the resident’s room, placing the Administrator on speaker so she could hear the interview and reported events. Despite the Administrator being made aware of the allegation on the same morning it occurred, the facility did not document the incident in the resident’s medical record and did not report the allegation of sexual abuse to the state agency at that time. The internal investigation file for that date contained only brief, non-witness statements from staff attesting generally to the CNA’s behavior, with no detailed statements from the social worker designee, the human resources director, the LPN caring for the resident, or the CNA accused. The investigation summary concluded that the resident was confused and combative during personal care and that no abuse occurred, and the facility relied in part on the resident’s son’s opinion that an investigation was not needed and that the resident might have a urinary tract infection. Subsequently, when an SRI was entered into the state’s reporting system, it was categorized as physical abuse rather than sexual abuse, and there was no SRI entered for the original date of the allegation. A police report later documented that the Administrator reported the incident as sexual in nature and stated that the facility was not made aware of the allegation until the resident’s son reported concerns, which conflicted with staff interviews confirming the Administrator’s awareness on the date of the incident. The facility’s own abuse policy required that any allegation or suspicion of all types of abuse be reported to the state agency prior to investigation, but the allegation of staff-to-resident sexual abuse was not reported as such when initially known, and the investigation was incomplete and poorly documented.
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