Failure to Notify Responsible Parties of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to notify the responsible parties of two residents after an incident involving inappropriate physical contact between residents. According to the facility's own policies, family or responsible parties must be notified of any change in mental, psychosocial, or behavioral management, as well as any alleged violations involving abuse. In this case, a male resident with a history of dementia and behavioral issues was observed grabbing the back of a female resident's head and kissing her. The female resident, who also had dementia and was not her own responsible party, was unable to recall the incident and showed no immediate signs of distress. However, there was no documentation or evidence that her responsible party was notified of the event. Staff interviews and record reviews confirmed that the incident was reported internally to the RN, DON, and NHA, but none of them instructed staff to notify the responsible parties of either resident involved. Text messages reviewed by the LPN and RN indicated that the LPN had asked about notifying the responsible party but was told not to do so. The DON and NHA also confirmed that they did not notify the responsible parties and could not find any documentation that such notification occurred. Additionally, observations revealed that the male resident continued to display inappropriate behaviors, such as making sexual comments and gestures toward other residents and staff, and attempting to grab others. Despite these ongoing behaviors and the initial incident, there was still no indication that the responsible parties for either resident were informed, as required by facility policy. The failure to notify responsible parties of events that may have mental or psychological impact constitutes the deficiency cited in this report.