Failure to Change Security Code After Violent Incident
Penalty
Summary
The facility failed to change the security code for the gate and entrance door after an incident in which three unidentified individuals, allegedly known to a staff member, gained access to the premises and assaulted a Certified Nurse Assistant (CNA). Multiple staff interviews indicated that only facility staff should have knowledge of the gate code, but it was suspected that a staff member provided the code to unauthorized individuals. The incident was witnessed by other staff, who observed the perpetrators entering the facility's gated parking lot and subsequently assaulting the CNA, resulting in visible injuries such as a struck head, facial injuries, and the CNA falling to the ground. Despite the breach and the violent event, the facility did not change the access code following the incident. Staff expressed concerns about the ongoing safety risk due to the unchanged code, noting that this failure could allow unauthorized individuals to re-enter the premises. The facility's policy required investigation of such incidents and corrective action, but the report indicates that the code remained unchanged after the event, leaving staff and residents vulnerable.