Failure to Consistently Enforce Resident Separation During Abuse Investigation
Penalty
Summary
The facility failed to consistently implement effective separation measures to prevent further abuse during an ongoing abuse investigation involving two residents. After an incident where one resident was observed with their hand in another resident's brief, staff separated the residents and notified appropriate personnel. However, subsequent observations revealed that both residents continued to be in close proximity at the nurse's station, with one resident talking to the other and a staff member present but not actively monitoring their interaction. Interviews with staff indicated that instructions were given to keep the residents an arm's length apart, but this was not consistently enforced, as evidenced by the residents being observed near each other and interacting. The resident who was the subject of the abuse investigation had diagnoses including anxiety disorder, delirium, and insomnia, and required staff assistance with mobility and transfers. Despite the facility's policy requiring separation of residents involved in suspected abuse, the alleged perpetrator continued to have access to the other resident during the investigation period. Staff interviews confirmed that the separation protocol was not always maintained, and the resident continued to express concern about the other individual when they were in proximity.