Failure to Protect Resident from Abuse Due to Inactive Safety Interventions
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse during a resident-to-resident incident. On the morning of the incident, a nursing assistant found one resident on top of another in a private room, with the resident on top disrobed from the waist down and making thrusting motions, while the other resident was fully clothed. The incident was discovered during routine rounds, and both residents were separated and assessed. The resident who was found on the bottom had severe cognitive impairment, a history of wandering, and had previously entered other residents' rooms, including the room of the resident involved in this incident. The care plan for this resident included interventions such as monitoring whereabouts, redirecting from other rooms, and placing a stop sign at the doorway to deter entry. The resident whose room was entered had a diagnosis of dementia but was cognitively intact according to recent assessments. This resident's care plan included a motion sensor at the door to alert staff if someone entered the room, as well as a stop sign to deter entry. Previous nursing notes documented prior incidents of the wandering resident entering this room and touching the resident inappropriately, which led to the implementation of the motion sensor and stop sign interventions. Physician orders required the motion sensor to be plugged in at a specific time each morning and unplugged at night, with documentation in the treatment administration record (TAR). On the day of the incident, staff interviews and record reviews revealed that the motion sensor alarm was not plugged in as ordered, and there was no documentation in the TAR to confirm it was activated. Staff who responded to the incident noted that the alarm did not sound when they entered the room, and the Director of Nursing confirmed that the sensor was not plugged in at the time. There was no evidence provided that the resident was kept free from abuse, as required by facility policy and regulatory standards.