System or Discrete Failure?
Let's look at an example of a situation in which a direct care staff (DCS) confessed that he had been abusing individuals.
This could represent a system failure OR a discrete failure.
How could it be a system failure?
- Perhaps staff suspected or observed the abuse and failed to report the incident to administration, or if the facility failed to screen the applicant before hire.
How could it be a discrete failure?
- Perhaps the DCS worked by himself, there were no physical signs of abuse, his victims were not able to communicate, and the facility had no reason to suspect abuse was occurring.