Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse between residents to the State Agency and other required authorities, as mandated by regulation and facility policy. Resident #1 was a cognitively severely impaired female with a history of cerebral infarction, bipolar disorder, memory deficit, left-sided paralysis, TIA, depression, fall risk, social isolation, and a documented care plan entry indicating risk for re‑traumatization related to prior trauma from other resident violence. Resident #2 was a cognitively severely impaired male with vascular dementia with mood disturbance, depression, cerebral infarction, and cognitive communication deficit. Both residents had care plans reflecting significant cognitive and functional impairments. A third resident (Resident #3) reported witnessing Resident #2 place his hand between Resident #1’s legs and touch her private area while they were seated together in the dining room, with no staff present at the time. The DON stated she was informed toward the end of January that Resident #2 attempted to touch Resident #1 while they were in the dining room. She reported that the incident was reported by a staff member, though she could not recall who, and that she did not consider the allegation valid because both involved residents denied the incident when questioned. Based on this, she did not report the allegation to the State. The Administrator, who served as the abuse coordinator, stated he was informed by a staff member (whom he could not identify) that Resident #2 touched Resident #1 in her private area while they were in the dining room. He confirmed that the residents were separated and that Resident #2 was placed on 1:1 and later transferred, but he did not report the allegation to the State Agency, citing both residents’ low BIMS scores, confusion, and the fact that Resident #2 was in the process of being transferred. When interviewed, Resident #1 denied being touched or hurt and was unable to recall any inappropriate touching. Review of Resident #1’s EMR revealed no progress notes, incident reports, or witness statements regarding the allegation, despite the facility’s written abuse policy requiring that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate State or Federal agencies within applicable timeframes.
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