Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to prevent resident-to-resident abuse when one resident with a history of inappropriate sexual behavior and severe cognitive impairment was able to have unsupervised access to another resident. The resident with high-risk heterosexual behavior and a BIMS score indicating severe cognitive impairment was care planned for behavioral problems, including inappropriate sexual behavior, with interventions to protect others. Despite these interventions, the resident was observed by an LPN holding another resident's hand, attempting to kiss his hands and arms, and pulling on his arm while the other resident tried unsuccessfully to pull away. No staff were present at the nurses' station at the time, as CNAs were making rounds, allowing the incident to occur without immediate intervention. The second resident involved had diagnoses including Alzheimer's disease, dementia, and impaired cognitive function, and was care planned for self-care deficits, aggression, wandering, and resistive behaviors. The incident was witnessed by an LPN, who intervened to separate the residents and was assisted by another staff member. The lack of supervision and failure to implement effective interventions allowed the opportunity for the inappropriate contact to occur, constituting a failure to protect residents from abuse as required by facility policy.