Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse perpetrated by other residents. One resident with a history of sexually inappropriate behavior, including vulgar comments and obscene language, was found unsupervised in the activity room with another resident, with his hand on the other resident's breast. The resident who committed the act had a documented history of sexual remarks and behaviors, as well as diagnoses including Paranoid Schizophrenia, Vascular Dementia, Bipolar II Disorder, and Borderline Personality Disorder. Despite this history and a recent reduction in antipsychotic medication, the facility did not implement or document enhanced supervision or monitoring, and staff failed to complete required behavior monitoring documentation. The care plan for this resident did not provide clear direction regarding supervision requirements, and staff interviews confirmed that residents were left unsupervised in the activity room, contrary to facility policy. Additionally, the facility failed to protect two other residents from physical abuse. In one incident, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident in the face following a dispute over a bedside table. The care plan for the aggressive resident did not specify the level of supervision required to ensure the safety of others. Staff interviews and facility records confirmed that the incident resulted in physical injury and was substantiated as physical abuse. In another incident, a resident with a history of behavioral issues hit another resident on the arm, but details of this event were not fully elaborated in the provided excerpt. The facility's policies required ongoing oversight, supervision, and individualized care planning for residents with behaviors that could lead to conflict or abuse. However, the facility did not ensure that these policies were implemented as written. Staff interviews revealed a lack of awareness regarding supervision requirements, and documentation showed that behavior monitoring was incomplete or missing. The failure to provide adequate supervision and to follow established care planning and monitoring protocols directly contributed to the incidents of abuse.