Failure to Monitor Visitation Following Abuse Allegation
Penalty
Summary
The facility failed to protect a resident from abuse by allowing the resident's wife to visit without close monitoring, despite previous allegations of physical abuse. The resident, who had severe protein-calorie malnutrition and dementia, reported to staff that his wife had smacked him on the thighs and slapped him on the cheek. The care plan required that the wife’s visits be limited to common areas and closely monitored, but staff interviews and observations revealed that the wife was allowed to visit the resident in his room unsupervised on multiple occasions. Several staff members, including CNAs and licensed nurses, were unaware of the abuse allegation and the specific visitation restrictions in place for the resident’s wife. The facility’s policies allowed for visitation restrictions in cases of suspected abuse, but staff failed to implement or communicate these restrictions effectively. The Director of Nursing and Administrator confirmed that visits should have been monitored and limited to public areas, but staff assigned to the resident did not receive this information. As a result, the resident’s wife was able to visit and assist the resident in his room without supervision, contrary to the established plan of care and facility policy.