Failure to Prevent Unauthorized Entry and Resident Abuse
Penalty
Summary
The facility failed to ensure resident safety by allowing a former resident, who had been discharged and issued a no-trespass order, to repeatedly gain unauthorized entry into the building through an unsecured door without staff awareness. This resulted in non-consensual contact when the former resident entered a female resident's room at night and kissed her on the forehead, causing her mental anguish and difficulty sleeping. The former resident also misappropriated property from another resident and was observed in multiple areas of the facility after discharge, including attempting to sleep in his old room and interacting with residents on various floors. Staff interviews revealed that the former resident was able to enter the building undetected on several occasions, often due to the front door being propped open by residents, and that staff were not always aware of his presence or the trespass order in place. The report documents that the former resident had a history of behavioral issues, including increased aggression towards staff and residents, frequent intoxication, and providing alcohol to other residents. Despite being discharged against medical advice and given a trespass order, the former resident continued to return to the facility, sometimes entering the building and resident rooms, and at other times remaining just outside the property. Police were called multiple times, but the former resident often left before their arrival. Staff and residents reported feeling unsafe, and some residents expressed a desire to file restraining orders due to the former resident's threats and inappropriate behavior. The facility's front door was identified as a key vulnerability, as it was often left propped open, allowing unauthorized access. Additionally, the facility failed to protect two residents from abuse when another resident engaged in a verbal and physical altercation with one resident, which escalated to a physical incident with a second resident later the same day. Documentation and interviews confirmed that staff were aware of the altercations but did not implement effective interventions to prevent further incidents. The affected residents had various medical and behavioral diagnoses, including alcohol dependence, depression, and physical disabilities, but were generally independent in their self-care. The facility's lack of effective monitoring and response to both the unauthorized entries and resident-to-resident altercations resulted in a finding of Immediate Jeopardy, placing all residents at risk.