Failure to Implement and Document Password Protocol for Resident Safety
Penalty
Summary
The facility failed to implement and document a password protocol intended to protect a resident with moderately impaired cognition and a history of being at risk from outside parties. The resident, who had diagnoses including dementia, respiratory failure, atrial fibrillation, and anxiety, had a banner alert in the clinical record indicating that the resident's son was trespassed and that no information was to be shared. Despite this, the care plan did not include a safety plan, and the clinical record did not document the password protocol. A progress note indicated that a password protocol was implemented after an incident where parties entered the resident's room and created a disturbance, but these parties were unaware of the password requirement. Interviews with staff, including a CNA, LPN, the Director of Social Services, and the Executive Director, revealed that the password protocol was not documented in the resident's chart and that staff could not identify what the protocol was. The facility's policies required protection from abuse and the implementation of resident-specific safety interventions, but these were not followed in this case. The lack of documentation and communication regarding the password protocol resulted in a failure to ensure the resident's safety as required by facility policy.