Failure to Protect Residents from Abuse and Inadequate Documentation
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident sexual and physical abuse, as evidenced by multiple incidents involving four residents. One cognitively intact resident entered the room of a severely cognitively impaired resident on more than one occasion and engaged in inappropriate sexual contact, including groping and exposing the resident. Staff members witnessed these incidents, and there was evidence that the cognitively impaired resident was unable to recall or report the events due to her condition. Despite these occurrences, the care plan for the cognitively impaired resident did not address her risk for abuse or include interventions to protect her from further harm. Additionally, the facility failed to document the incidents and necessary interventions in the medical records of both the perpetrator and the victim. The cognitively intact resident's record did not reflect the sexual abuse allegations or the rationale for increased supervision, and the cognitively impaired resident's records lacked documentation of the abuse incidents and protective measures. Staff interviews confirmed that the administration was aware of the incidents, but appropriate documentation and care plan updates were not completed at the time of the events. A separate incident involved a resident with a history of physical aggression due to dementia and mood disorders physically striking her roommate during care. The aggressive resident's care plan noted her behavioral issues and triggers, but the incident still occurred, resulting in the roommate being hit on the shoulder. Staff and the roommate confirmed the aggressive behavior, and the facility's records corroborated the event. These failures to prevent and appropriately respond to abuse led to the finding of Immediate Jeopardy.