Failure to Protect Resident from Abuse and Unsafe Interactions During Family Visits
Penalty
Summary
The facility failed to ensure the safety and prevention of abuse for a resident with cognitive communication deficits and generalized anxiety disorder. The resident, who had a moderate cognitive loss as indicated by a BIMS score of 7, experienced multiple incidents involving their spouse during visits. These incidents included the spouse making physical contact with the resident's face, reopening a skin tear by pulling the resident's arm, and administering unidentified medication and aspirin to the resident. Additionally, the spouse fed the resident unsafe food items and repositioned the resident without staff involvement, sometimes leading to arguments with staff and increased resident anxiety and aggression. Despite these repeated incidents, the resident's care plan did not include interventions or monitoring related to the spouse's visits, nor did it address the spouse's involvement in feeding, medication administration, or physical contact. The care plan only noted the resident's potential for verbal aggression and included general interventions for de-escalation and psychiatric support, but lacked specific guidance for staff regarding the spouse's actions. The resident profile assignment sheet also did not reflect any safety concerns or behavioral issues for this resident, leaving staff without clear written instructions for safeguarding the resident during spouse visits. Interviews with staff and the administrator confirmed that only verbal instructions had been given to monitor the resident during spouse visits, and that the care plan and assignment sheets had not been updated to reflect the ongoing issues. The administrator acknowledged awareness of the spouse's actions and the lack of documentation or formal interventions in the care plan or assignment sheets. The facility's policy required identification and intervention in situations where abuse is more likely to occur, but this was not implemented in the resident's documented care.