Failure to Implement and Communicate Abuse Prevention Interventions
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of dementia was subjected to inappropriate sexual contact by another resident, who also had severe cognitive impairment and behavioral disturbances. The incident occurred in a common area and was witnessed by a registered nurse, who intervened and separated the residents. The nurse reported the incident to the nurse manager later in the day after being advised by another nurse that it needed to be reported. The initial response included documenting the incident and notifying management. Following the incident, the care plan for the resident who committed the inappropriate act was updated to include 1:1 supervision and the installation of a motion sensor alarm on the resident's doorway and bathroom. However, during subsequent observations, these interventions were not consistently implemented. Staff were observed leaving the resident unsupervised in common areas, and the motion sensor alarm did not always function as intended. Additionally, the care plan interventions were not reflected in the CNA Kardex, and staff were not consistently aware of the required supervision or interventions. Interviews with multiple staff members revealed a lack of awareness and education regarding the updated care plan interventions. Some staff had not received any education since returning from leave, and there was confusion about how care plan changes were communicated and implemented. The facility's documentation showed that only a fraction of the staff had signed off on education related to the incident, indicating a gap in staff training and communication. These failures resulted in the resident not being adequately protected from further abuse, as required by regulations.