Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from abuse by another resident. One resident with severe cognitive impairment and a history of trauma was found in her room with another resident, also severely cognitively impaired, whose hand was under the blanket on her bed. Staff observations and interviews confirmed that the male resident had previously made inappropriate comments and attempted to enter the female resident's room on multiple occasions. Both residents were assessed as unable to consent to sexual activity, and the incident was reported to the State Agency. Despite facility policies requiring protection from abuse and interventions for residents with wandering or aggressive behaviors, the male resident was not adequately supervised. The facility's interventions included 15-minute checks and direct supervision, but surveyors observed that these checks were not consistently performed. After the initial incident, the male resident was able to enter the female resident's room on at least four additional occasions, and staff could not always verify whether the female resident was present during these times. Staff interviews revealed that the male resident continued to attempt to access the female resident's room, and that staff were sometimes too busy to prevent these occurrences. The facility did not complete all required staff education following the incident, and there was no documentation to confirm that additional abuse prevention training had been provided. Interviews with staff and family indicated that the female resident experienced emotional distress, including fearfulness and crying, following the incident. The facility's failure to implement and maintain effective supervision and monitoring allowed repeated access by the male resident to the female resident's room, resulting in a failure to protect her from potential further abuse.