Failure to Protect Resident from Mental and Psychosocial Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from mental and psychosocial abuse, specifically involving resident-to-resident interactions. Resident #106, who was cognitively intact with a BIMS score of 15/15, experienced mental anguish and fear due to the behavior of Resident #105. Resident #105, who also had a BIMS score of 15/15, exhibited behaviors such as staring, aggressive verbal interactions, and inappropriate sexual conduct, which were not adequately addressed by the facility. Staff members, including a registered nurse, a certified nursing assistant, and a licensed practical nurse, observed and reported Resident #105's behavior towards Resident #106. Despite these observations and reports, the facility's administration, including the Nursing Home Administrator, did not conduct a thorough investigation or implement sufficient measures to protect Resident #106. The facility's inaction led to Resident #106 feeling unsafe and fearful, impacting her ability to move freely within the facility. The facility's policies on abuse prevention and response were not effectively implemented, as evidenced by the lack of immediate action following the incidents. The Interdisciplinary Team discussed potential interventions, such as increased supervision and door alarms, but these were not promptly executed. The failure to address Resident #105's behavior and protect Resident #106 from mental and psychosocial abuse constitutes a deficiency in the facility's duty to ensure a safe environment for all residents.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.