Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident approached and kissed him on the lips without consent in a common area. The incident was witnessed by a CNA, who reported it to an LPN. The resident who was kissed had a history of being rarely or never understood, with diagnoses including unspecified intracranial injury, bipolar disorder, and anxiety disorder. The resident who initiated the contact had a documented history of behavioral issues, including sexual inappropriateness, psychosis, and other disruptive behaviors. Documentation revealed that the resident who was kissed did not initially respond to questions about the incident, but later interviews indicated he felt abused by the event and expressed a desire not to reside on the same unit as the other resident. The resident who initiated the contact was sent to the hospital following the incident. Staff interviews and progress notes confirmed that the incident was categorized as alleged physical abuse, but the facility concluded that abuse did not occur. However, the surveyor's interview with the affected resident revealed he felt abused and did not want to remain on the same unit as the other resident. The facility's records showed that the resident who initiated the inappropriate contact had a known history of sexually inappropriate behaviors and other disruptive actions, yet remained on the same unit as vulnerable residents. The incident was not documented in the initial physician assessment for the affected resident, and there was no evidence that the resident's expressed wishes to be moved were known to staff prior to the surveyor's interview.