Failure to Report and Accurately Disclose Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility Administrator’s failure to effectively administer the facility by not properly reporting and characterizing an allegation of staff-to-resident sexual abuse and by providing false information to police. The resident involved had multiple medical conditions including stroke, dementia with severe cognitive impairment, depression, and functional dependence requiring extensive assistance of two staff for bed mobility, transfers, and ambulation. Her care plan noted alterations in mood and behaviors, including occasional delusional thinking and yelling out. On the morning in question, the resident reported that a male staff member tried to put his “thing” in her mouth, gesturing toward her own and the nurse’s private areas, and identified the alleged perpetrator by name and description, which matched a CNA on duty. Staff interviews showed that the allegation was promptly brought to facility leadership on the same morning it occurred. An LPN, after hearing the resident’s statements, reported the concern to the social worker designee because administration was not yet on site. The social worker designee and the Human Resources Director jointly interviewed the resident, who remained upset and repeated the allegation, and they confirmed that the CNA she identified matched the description she gave. The Human Resources Director called the Administrator on speaker phone during this interview so he could hear the resident’s statements and the reported events. The Administrator then spoke with the CNA by phone, in the presence of the social worker designee and Human Resources Director, and directed the CNA to leave the facility pending investigation. Despite being made aware of the allegation on the day it occurred, the Administrator did not report the allegation of sexual abuse to the state agency as required by the facility’s abuse policy, which mandates reporting all allegations or suspicions of abuse prior to investigation. Review of the state reporting system showed no self-reported incident for sexual abuse on the date of the allegation, and when an incident was later entered, it was reported as physical abuse rather than sexual abuse. Additionally, in a subsequent police report for a sex offense, the Administrator told law enforcement that the facility was not made aware of the allegation until the resident’s son reported concerns two days after the incident, which conflicted with consistent staff statements that the Administrator had been immediately informed on the day of the alleged abuse. These actions and omissions constituted a failure of effective facility administration.
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