Failure to Follow Care Plan Leads to Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by not following an existing care plan intervention to keep the resident away from members of the opposite gender. One resident with dementia and severe cognitive impairment, documented by a BIMS score of 7/15, had a care plan focus area noting increased episodes of sexually inappropriate behavior toward other residents, with an intervention to seat the resident away from residents of the opposite gender in the dining room. On the date of the incident, this resident was seated in the community room between two residents of the opposite gender, including another resident with dementia, mood and behavioral disturbance, unspecified psychosis, and a BIMS score of 1/15. Surveillance video reviewed by surveyors showed that two staff members were present in the area and did not separate the resident from residents of the opposite gender as required by the care plan. An altercation occurred in which the second resident struck the care-planned resident in the eye and forehead, causing a small laceration to the left forehead and a bleeding scratch under the right eye. A facility incident report documented that the second resident struck the first resident with a fist after the first resident allegedly attempted to touch the second resident’s genital area. A nursing assistant later stated she had been told that the first resident attempted to touch the second resident’s groin, but also reported that after facility staff reviewed the surveillance video, it was determined that no such attempt occurred. A registered nurse reported that the two residents “don’t mix” and that staff try to keep them separated, and also confirmed that the resident with sexually inappropriate behaviors was to be kept away from residents of the opposite gender for a long time. The DNS and Administrator were unable to provide evidence that the care plan intervention to keep the resident away from residents of the opposite gender was followed, and the Administrator could not provide evidence that the resident was kept free from physical abuse.
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