Failure to Implement Abuse Prevention Policies Leads to Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Specifically, the facility did not identify or address at admission a resident's history of inappropriate sexual behavior, which resulted in an incident where this resident placed her hand inside another resident's underwear. The staff did not review the admission documents thoroughly, missing multiple documented incidents of inappropriate sexual behavior from the transferring facility. Key staff members, including the DON, social worker, MDS coordinator, and admission coordinator, were unaware of the resident's behavioral history at the time of admission, and the care plan did not initially reflect the need for interventions to address these behaviors. The incident occurred when the resident with a history of inappropriate sexual behavior was left unsupervised in another resident's room. The assigned 1:1 observation for the potential victim was not maintained due to a lapse in staff coverage during a shift change, and staff were unclear about their responsibilities regarding 1:1 supervision. Multiple CNAs and nurses reported not being informed about the need for close supervision or the specific risks posed by the resident with a history of sexual behaviors. As a result, the resident was able to enter another resident's room and engage in inappropriate contact without immediate intervention. Interviews and record reviews revealed that the facility's staff were not adequately trained or informed about the policies and procedures for preventing abuse, neglect, and exploitation, particularly in relation to residents with known behavioral risks. The lack of communication and documentation regarding supervision assignments, as well as the failure to review and act upon critical information in the admission packet, directly contributed to the incident. The facility's policies on abuse and neglect were not effectively implemented, and staff did not consistently follow procedures for monitoring and protecting residents at risk.