Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident was inappropriately touched by another resident in the dining room without staff supervision. The incident was witnessed by the Activities Director, who observed one resident touching another's breast. At the time, there were three to four residents present in the dining room, but no staff were supervising. The Activities Director intervened immediately upon witnessing the event. Prior to the incident, staff had discussed the resident who committed the inappropriate act as having exhibited sexual behaviors, and some staff had warned others to be cautious when providing care to this resident. However, no formal reports of inappropriate or sexual behavior had been made to the Director of Nursing before the incident. The resident who was touched had a history of cognitive impairment, with a BIMS score indicating moderate impairment, and required assistance with activities of daily living, including bowel and bladder incontinence. The resident who committed the act also had significant physical and cognitive care needs, including hemiplegia, reduced mobility, and incontinence. The lack of staff supervision in the dining room allowed the incident to occur, despite prior informal awareness among staff of the perpetrator's inappropriate behaviors.
Plan Of Correction
Element #1 On March 3, 2025, immediately following the incident, the Activities Director separated residents R504 and R505 and reported the incident to the facility's Abuse Coordinator and Administrator in accordance with the facility's abuse policy. A full investigation was initiated within the required timeframe, including interviews with involved staff and residents, and findings were documented per regulation. Resident R504 was assessed for physical and emotional well-being by nursing and social services and monitored closely for psychosocial distress. Resident R505's care plan was immediately updated to reflect the behavior, with interventions including 1:1 supervision during group activities, increased monitoring, and review of the need for behavioral health support. R505 was moved to a different unit with staff trained to supervise higher-risk behaviors and reduce the risk of future interactions with R504. Element #2 The facility conducted a full audit of all residents with a known history of behavioral challenges, cognitive impairments, or psychiatric diagnoses to determine if any similar incidents or risks were present. No further noncompliance or similar incidents were identified during this audit. Element #3 Revised supervision in the dining room from the Activities department was implemented requiring an increased presence in dining/activity rooms when residents are present. No additional cases of resident-to-resident inappropriate behavior were identified during the audit. All staff, including nursing, activities, and ancillary services, were re-educated on the Abuse Policy and procedures, how to identify and document inappropriate behaviors, immediate response steps to peer-to-peer abuse, and enhanced supervision strategies. The policy for abuse and neglect was reviewed by the IDT Team and deemed appropriate. Element #4 The Director of Nursing or designee will conduct weekly rounds for four weeks then once a month for three months until QAPI determines sustained compliance in communal areas to verify active supervision and implementation of care plan interventions. The IDT Team will hold weekly At-Risk Meetings to monitor residents with high-risk behaviors and review behavior logs. All reported incidents involving potential abuse, elopement risk, or behavioral triggers will be reviewed monthly in QAPI meetings to identify trends and provide ongoing solutions. A monthly audit of care plans for residents with behavioral or cognitive concerns will be conducted to ensure individualized supervision strategies are in place and staff are aware of them. The QAPI committee will review audit results monthly and ensure any issues are corrected. The Facility Administrator will be responsible for maintaining compliance.