Failure to Provide Adequate Supervision Resulting in Resident-to-Resident Incident
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for two residents with severe cognitive impairment residing on the memory care unit. On the date of the incident, one female resident with Alzheimer's disease and severe cognitive impairment was found fully clothed in the bed of a male resident, who was undressed below the waist. Both residents were in the male resident's room, and the event was discovered by a CNA during routine rounds. The CNA immediately intervened, separated the residents, and called for nursing assistance. Record reviews indicated that the female resident had a history of wandering behaviors and severe cognitive impairment, as reflected by a BIMS score of 00. The male resident, while having a BIMS score indicating intact cognition, had diagnoses including unspecified dementia with agitation and schizophrenia. Prior to this incident, neither resident had documented sexually inappropriate behaviors in their care plans. Staff interviews confirmed that the incident was the first of its kind for both residents, and the intent behind the interaction was unknown. The facility's failure to provide adequate supervision allowed the female resident to wander into the male resident's room and resulted in both residents being found in a compromising situation. Staff were unable to specify when the residents were last seen prior to the incident, and the event was only discovered during routine staff rounds. The incident placed residents at risk for abuse, as noted in the report.