Failure to Provide Adequate Supervision Resulting in Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for two residents, resulting in one resident with a history of sexual behaviors inappropriately touching another resident. Both residents had severe cognitive impairment and behavioral issues, with one resident previously placed on 1:1 supervision due to aggression. Despite this, the resident was left alone in her room with another resident known for impulsive sexual behavior, leading to an incident where inappropriate contact occurred. Staff interviews and record reviews revealed that the assigned 1:1 supervision was not consistently maintained. The CNA assigned to 1:1 observation did not start her shift on time, and other staff were unaware of the need for close supervision or the specific behavioral risks of the residents involved. Communication lapses occurred during shift changes, and staff were not fully informed about the residents' histories or the requirements for 1:1 observation. Additionally, the care plans and admission documentation did not adequately reflect the residents' behavioral risks, and several staff members were unaware of the need for heightened supervision. The facility's policies required specific levels of observation and clear staff assignments for residents at risk, but these were not followed. The lack of proper hand-off procedures, incomplete staff training on observation protocols, and failure to review admission documentation for behavioral risks contributed to the incident. The deficiency was identified as Immediate Jeopardy due to the failure to provide the required supervision, which allowed the incident of inappropriate sexual contact to occur.