Failure to Protect Resident from Mental Abuse by Family Member
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of physical and emotional abuse from further mental abuse by a family member. The resident, who had diagnoses including confirmed physical abuse, major depressive disorder, and anxiety disorder, had an open Adult Protective Services (APS) case against a specific family member. The resident had clearly expressed to the facility's interdisciplinary team and case manager that she did not want any contact, calls, or visits from this family member, citing a long history of various forms of abuse. The care plan and medical record documented these wishes, and staff were notified accordingly. Despite these documented restrictions, the family member was able to enter the facility on two separate occasions. On the second occasion, the family member bypassed safety checks, pushed past staff, and attempted to enter the resident's room while she was receiving perineal care, trying to pull back the privacy curtain and shouting at the resident. The resident was visibly distressed, shaking her head no, tearful, and later required medication for anxiety. Staff intervened and called the police to remove the family member from the premises. The resident's emotional distress was documented, and a new order for Ativan was issued to manage her anxiety following the incident. The facility failed to implement its own abuse prevention policy, which required protecting residents from all forms of abuse, including mental abuse, and ensuring the health and safety of residents regarding visitors. The policy also indicated that room changes should be considered for resident safety, but there was no evidence that a room change was offered after either incident. Additionally, the administrator did not conduct a thorough investigation or report the incident to the state agency, as required by policy, due to incomplete information from staff. The resident's name remained posted outside her room, which may have facilitated the family member's access.