ALBUQUERQUE, NM- SANDIA RIDGE CENTER

Based on record review, and interview the facility failed to prevent resident to resident abuse for 2 [R #16 and 224] of 5 [R #s 16, 42, 60, 224 and 265] residents reviewed for abuse and neglect by not providing enough supervision for a resident with known sexually inappropriate behaviors and not implementing additional interventions to protect residents. This deficient practice likely resulted in psychosocial harm to residents.

Record review of the nursing progress notes for R #265 dated 04/06/21, indicated the following, Received report from CNA [Certified Nursing Assistant] this morning that resident was in his room with his pants down and his hands on his penis playing with himself. He was spraying his bodily fluids on the floor and on the wall. Resident [R #265] came to the entry way of the room and was trying to lure female residents in the room.

During an interview with Licensed Professional Nurse [LPN] #7, she stated he was very perverted, from the day he got here. He would make nasty comments to staff. At first it was directed to staff, then he directed it to residents. She stated that he would stand in his door way naked, he would pee in trash cans.

During an interview with Certified Nursing Assistant #5, she stated  that it makes it hard to keep an eye on everyone. CNA #5 stated that R #265was tall and very strong, he intimidated the staff. She did not like working with him and felt like she needed to protect the other residents from him.

During an interview with Family Member [FM] #1, she stated that there was a resident [R #265] to resident [R #16] abuse on May 2021. She stated that resident [R #265] sexually assaulted her mother [R #16] back on May 15, 2021. She stated that R #265 was known to the facility to have sexually inappropriate behaviors by the staff. She stated that the staff told her that they keep an eye on him but at some point they got busy and lost track of him. FM #1 stated that a staff member was checking on the residents and that R #265 peeked out of a female’s room and slammed the door when he saw the staff member. The staff member wasn’t able to immediately gain entrance into the room because the facility investigation revealed that R #265 was blocking the door. The staff member did get into the room and the resident threw a chair at the staff member [not hitting the staff]. R #265 was asked to leave, and they did get him out of the room. They asked R #16 if he had hurt her, and she indicated that he had sexually touched her. 

On 11/23/21 at 11:46 am, during an interview with Unit Manager #1,  it was stated having more staff on that unit monitoring would have helped and may have prevented the incident.