Failure to Assess Resident After Unsolicited Physical Contact
Penalty
Summary
A deficiency occurred when staff failed to complete a resident assessment for the physical and emotional well-being of a resident who experienced unsolicited touching by another resident. The incident involved two residents, both with dementia and other cognitive impairments, who were independently ambulating in wheelchairs in a hallway unmonitored by staff. One resident approached the other, rubbed her leg, and later touched her private area without consent. Staff were not present to intervene during the initial incident, and when a CNA did encounter the residents, she did not immediately separate them or stop the inappropriate behavior. The nurse on duty was not aware of the proximity of the residents and did not witness the incident directly. Following the incident, the nurse did not conduct a timely assessment of the affected resident's physical or emotional state. Although the nurse documented a progress note based on secondhand reports from staff and housekeeping, she did not complete an incident report or perform an immediate assessment. The only assessment of the resident's vital signs occurred two days later, after the DON returned and inquired about the event. There was no documentation of a thorough evaluation of the resident's well-being or any follow-up notes addressing the incident's impact on her. The facility's policies required close monitoring of the resident with a history of sexually inappropriate behavior, including 1:1 supervision within arm's length in common areas. Documentation and staff meeting notes reiterated this requirement. However, video footage and staff interviews confirmed that this supervision was not maintained at the time of the incident. Additionally, the facility lacked a clear policy for incident reporting, relying instead on an electronic documentation system with dropdown options, which did not ensure that all necessary steps, such as resident assessment, were completed after such incidents.