Failure to Protect Cognitively Impaired Resident from Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of wandering was found in another resident's bed. The cognitively impaired resident had diagnoses including unspecified dementia, cerebral infarction, and unspecified psychosis, and was known to wander into other residents' rooms. The care plan for this resident identified risks for abuse, neglect, and exploitation, and included interventions such as assessment for signs of abuse and prompt investigation of any allegations. Despite these interventions, the resident was able to enter another resident's room and bed without effective prevention. The other resident involved was cognitively intact and admitted to touching the impaired resident's breasts at the request of the impaired resident. There was no prior documentation or care plan indicating that this resident exhibited any sexually inappropriate behavior. Staff interviews confirmed that the cognitively impaired resident was known to wander and had previously entered other residents' rooms and beds. At the time of the incident, the impaired resident was found partially undressed in the other resident's bed, and was unable to recall the event or appear distressed during subsequent interviews. The facility's investigation concluded that no abuse had occurred, citing a lack of malicious intent. However, the impaired resident's inability to make sound decisions and the failure to prevent the incident despite known risks and existing care plans led to the deficiency. The facility's policy required processes to prevent and report suspected or alleged abuse, neglect, or exploitation, but these processes were not effectively implemented to protect the resident from abuse in this instance.