Failure to Timely Report Alleged Sexual Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an alleged incident of abuse was reported immediately, and no later than two hours after the allegation was made. During the night shift at approximately 3:00 AM, an LVN observed a male resident in the room of two female residents. The LVN reported finding the male resident feeling around on one female resident’s bed as if trying to find his way back to bed, with the bathroom light on. This male resident had a history of wandering and visual impairment, and had previously wandered into other residents’ rooms. As the LVN and an aide escorted the male resident back to his room, the roommate followed and yelled that her roommate had been molested. The female resident who was the alleged victim was described in her records as an older adult with multiple medical conditions, including hypertension, acute embolism and thrombosis, acute respiratory failure, dysphasia, and reduced mobility. Her care plan reflected a BIMS score indicating moderately impaired cognition and a need for maximal assistance with most ADLs. When the LVN checked on her after the allegation, the resident was sound asleep with covers pulled up to her neck and undisturbed. The LVN did not complete a head-to-toe assessment at that time and only performed a general visual inspection, despite being aware of the allegation made by the roommate. The roommate, who also had moderately impaired cognition but required only setup or clean-up assistance with most ADLs, reported that the male resident had molested her roommate and later demonstrated to the Administrator that the male resident had been rubbing the alleged victim’s thigh and waist area. The LVN acknowledged that she had been trained on abuse and neglect reporting at the facility and knew the protocol, including the requirement to report allegations immediately. However, she did not notify the Administrator or DON of the allegation during the night shift and stated that it slipped her mind due to the busy shift and because she did not personally believe abuse had occurred based on her observations. She wrote the incident on a notepad but did not escalate it. The Administrator first learned of the allegation from the roommate around 11:00 AM, several hours after the alleged incident and the roommate’s initial statement to staff. The facility’s abuse policies required staff to report any suspected abuse to the Executive Director or DON and required covered individuals to immediately notify the Executive Director once they formed a reasonable suspicion that a crime had been committed, with subsequent reporting to law enforcement and the state survey agency within prescribed timeframes. The delay in reporting by the LVN, despite her training and the facility’s written policies, led to the cited deficiency for failure to report an alleged violation involving abuse within the required timeframe.
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