Failure to Report Resident-on-Resident Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to the state agency as required by policy and mandated reporter standards. Resident 1, who had a BIMS score of 12/15 indicating moderate cognitive impairment, reported that another resident (Resident 2) inappropriately touched her breasts without consent during a hug in a hallway. Resident 1 described that Resident 2 blocked her path, requested a hug, and as she pulled away, Resident 2 slid his hand over both of her breasts. She stated she immediately yelled at Resident 2, told him the action was inappropriate, felt violated, and later reported the incident to staff herself, after which she felt safe in the facility. The administrator stated that on 3/12/26 he was informed by staff that Resident 1 had reported the incident involving Resident 2 inappropriately touching her breast, and that an investigation was initiated. He further stated that Resident 1 requested the incident not be reported to any authorities, and based on that request, the incident was not reported to the state agency and was only reported to law enforcement. The social services director confirmed that Resident 1 reported that Resident 2 had touched her breast without consent and that Resident 1 requested the incident not be reported outside the facility. The social services director acknowledged that the incident was not reported as per facility policy, and stated that all staff were mandated reporters and the allegation should have been reported immediately. Interviews with facility staff and review of facility documents showed that the facility had a process and policy requiring immediate reporting of suspected abuse. The CNA stated it was facility process to report and investigate sexual abuse or any abuse allegation immediately to ensure resident safety. LVN 1 referenced the facility’s “Report of Suspected Dependent Adult/Elder Abuse” form, which stated that any mandated reporter who has knowledge of, is told of, or reasonably suspects abuse or neglect shall complete the form immediately or as soon as practicably possible for each known or suspected instance of abuse, including sexual abuse. LVN 1 stated that Resident 1’s report that Resident 2 touched both of her breasts without consent should have been reported immediately to ensure separation and safety. The clinical coach and administrator both stated that the facility process for an allegation of abuse was to ensure safety, separate residents, and report the incident immediately, and the facility’s “Unusual Occurrence Reporting” policy required reporting allegations of abuse to appropriate agencies. Despite these policies and staff understanding, the allegation of sexual abuse involving Resident 1 and Resident 2 was not reported to the state agency.
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