F0607

D

Failure to Notify Resident Representative of Sexual Abuse Allegation

Irving, Texas Survey Completed on 03-04-2026

Penalty

Fine: $15,935

Summary

The deficiency involves the facility’s failure to follow its own written abuse investigation and reporting policy by not immediately notifying a resident’s responsible party of an allegation of sexual abuse. The facility’s policy, revised July 2017, required the Administrator to keep the resident and representative informed of the progress and status of any abuse investigation and to report all alleged violations of abuse, neglect, exploitation, or mistreatment to the resident’s representative. An allegation was made that the Maintenance Director had exposed himself to a resident, and this information was relayed through another resident to a CNA, then to the Social Worker, and then to the Administrator. Despite this, the resident’s responsible party was not notified on the day the allegation was reported.

The resident involved was an elderly female with diagnoses including unspecified dementia, Alzheimer’s disease, chronic pain, depression, and sequelae of cerebral infarction. Her MDS showed a BIMS score of 3, indicating severe cognitive deficits, and documented that her preferred language was Spanish and that she required an interpreter for communication with healthcare staff. She required partial or moderate assistance with several ADLs, including toileting, bathing, dressing, transfers, and walking short distances, and had a history of refusing incontinence care and showers. Her care plans also noted mild depression and a preference for in-room, self-led activities, including Spanish-language media.

According to interviews and record review, the allegation that the Maintenance Director exposed himself to the resident originated when the resident reportedly told another resident, who then informed a CNA. The CNA reported it to the Social Worker, who reported it to the Administrator. The Administrator, who is married to the Maintenance Director, left the facility after learning of the allegation and handed the investigation over to the Executive Assistant. The Executive Assistant acknowledged that she did not notify the resident’s responsible party on the day the allegation was made and stated that she was new to the investigation process. Nursing staff who learned of the allegation later that day attempted to assess the resident, but the resident refused assessment and denied that anything had happened; the nurse was not instructed to notify the family and did not know whether they had been notified.

The resident’s responsible party later reported that she first learned of the allegation when the resident called her and said that the police were at the facility trying to speak with her about the allegation, and that the resident did not want to talk to them. The responsible party stated that facility staff routinely called her for relatively minor issues, such as the resident refusing showers, but no one contacted her about the abuse allegation. The Executive Assistant later confirmed that she met with the responsible party after the police involvement but had not contacted her on the day the allegation was reported. The Administrator also acknowledged that, in the usual process, the family would be notified immediately as part of completing the incident documentation, but that this did not occur because the appropriate incident template was not opened and the nursing portion of the investigation was not followed through. As a result, the facility did not implement its own abuse and neglect prevention policy regarding timely notification of the resident’s representative.