Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations due to its failure to conduct a thorough investigation into allegations of potential resident-to-resident abuse. The incident involved Resident CR1, who was observed masturbating in the doorway of his room, which was directly across from Resident 2's room. Despite being redirected by staff, Resident CR1 continued the behavior for a few minutes, visible to staff and other residents. The facility's policy mandates a comprehensive investigation into such incidents, but there was no documented evidence that this was done. Resident 2, who was potentially affected by the incident, was admitted to the facility with severe cognitive impairment, as indicated by a BIMS score of 00. This score reflects significant cognitive challenges, making it difficult for Resident 2 to describe or react to the incident. Resident CR1, on the other hand, was cognitively intact with a BIMS score of 13 and had a history of inappropriate sexual behavior, including a past conviction for a sexual offense. Despite these factors, the facility did not conduct a thorough investigation into the incident involving Resident CR1's behavior. Interviews with facility staff revealed that the social services director was unaware of any other residents involved in the incident, and the LPN who witnessed the event was not asked for further information. The Nursing Home Administrator confirmed the lack of a documented investigation, acknowledging the facility's responsibility to protect residents from abuse. The failure to investigate the incident thoroughly was a significant oversight, given the nature of the behavior and the potential impact on Resident 2.
Plan Of Correction
1. Resident CR1 has discharged from the facility. 2. Current residents have been interviewed. No residents report any knowledge of Resident CR1 behavior, sexual gratification, on the identified date. No residents or staff report an allegation of abuse related to resident R #1 behavior, on the identified date. 3. Facility staff will be re-educated by the NHA and or designee to the facility policy for abuse reporting and investigation to rule out potential resident abuse. 4. The Inter Disciplinary Team will audit resident progress notes, daily as part of the facility Clinical meeting process, to identify any instances of resident behavior requiring initiation of abuse reporting and investigation. If an allegation of abuse is identified, NHA and DON will follow abuse investigation policy. All abuse investigations will be submitted to and reviewed by the facility QAPI Committee.