Failure to Prevent Abuse and Neglect in LTC Facility
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. Resident 102, who was moderately cognitively impaired, had a documented history of sexually inappropriate behavior. Despite this, the facility did not implement sufficient interventions to prevent an incident where Resident 102 was observed holding Resident 289's hand on his genital region. Resident 289, who was severely cognitively impaired and unable to consent to sexual contact, expressed discomfort and confusion about the incident. The facility delayed reporting and implementing safety measures for two days after the incident. Additionally, the facility failed to prevent neglect of another resident, Resident 25, who required assistance from two staff members and a sit-to-stand lift for transfers. Employee 6, a nurse aide, assisted Resident 25 to the bathroom without following the care plan, resulting in the resident falling. The aide attempted to support the resident with her arm, but the resident became unsteady and fell, landing on his bottom. The Director of Nursing confirmed that the aide did not adhere to the care plan, which led to the fall. The facility's policies on abuse and neglect were not effectively implemented, as evidenced by the incidents involving Residents 289 and 25. The failure to address Resident 102's inappropriate behavior and the neglect of Resident 25's care plan requirements resulted in deficiencies in resident safety and care. These incidents highlight the need for the facility to ensure that staff are adequately trained and that care plans are strictly followed to prevent abuse and neglect.
Plan Of Correction
1. Resident 289 was discharged from the facility on 10/26/2024. A referral to psych services made for Resident 102 and an IDT approach continues. Resident 25 sustained no injury related to fall. Resident 25 was monitored for 72hrs and no change in condition was noted. Employee 6 was educated regarding reading residents' Kardex prior to providing care as well as abuse and neglect. 2. Residents of the facility have the potential to be affected by deficient practice. Staff records will be audited for Abuse/Neglect training over the past 12 months. Clinical Coordinator or designee will review new-hire CNA records for training in reading and adherence to the resident plan of care. 3. CNAs will be educated regarding adherence to the resident's plan of care. Facility staff will be educated regarding Abuse and Neglect upon hire and annually. 4. Director of Nursing or designee will audit all changes to the resident Kardex and Tasks five (5) times per week during the business week for two (2) weeks then weekly for four (4) weeks until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.