Failure to Prevent Unreasonable Confinement and Sexual Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including unreasonable confinement and sexual exploitation, as required by its abuse policy. For one resident with cerebral palsy, severe intellectual disability, a BIMS score of 1/15, and dependence on staff for mobility and ADLs, staff and resident interviews indicated that a CNA placed the resident in his room and closed the door so she would not have to hear his vocalizations. The resident was described in the care plan and by staff as preferring to be in the common area near the nurses’ station, watching people and making his needs known through gestures and vocalizations. A CNA reported that on a specific day she observed another CNA put the resident in his room and close the door, and that the resident remained in the room for 45 minutes to an hour despite his preference to be out of the room. The resident’s cognitively intact roommate corroborated that staff sometimes shut the door when the resident wanted out of the room, and confirmed that the resident liked to be in the common area. The RN familiar with the resident stated that he did not like to be in his room and that staff understood his wishes through his grunting and pointing. She acknowledged that another CNA had reported to her that a CNA placed the resident in his room and closed the door, and that the roommate had activated the call light, after which the CNA entered, the resident pointed toward the door indicating he wanted out, and the CNA told him she would be back in a minute and then closed the door. The RN stated she relayed this information to the DON “in passing,” but there was no indication that this allegation was formally reported or investigated at the time. The deficiency also includes an incident of alleged sexual exploitation involving another resident with non-Alzheimer’s dementia, anxiety, depression, and a BIMS score of 8/15. A staff RN reported that she entered the resident’s room to administer medication and observed a female visitor with a child present kiss the resident twice on the mouth while holding him around the waist, and later saw them walking down the hall holding hands. The RN later learned the visitor was a facility cook who knew the resident prior to admission and had also requested to take another resident out overnight and obtain that resident’s medications without guardian permission. The facility’s abuse policy defined abuse to include involuntary seclusion and exploitation and required timely reporting and investigation, but did not specify how residents would be protected during an investigation, and the events described show that residents were subjected to alleged unreasonable confinement and potentially exploitative physical contact by a staff member/visitor.
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