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Scope: Isolated
Severity: Actual harm has occurred
Citation date: April 12, 2021
Corrected date: June 12, 2021
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #s NY 586 and NY 377) completed on 4/12/21, the facility did not ensure the resident's right to be free from sexual abuse for two (Residents #1 and #3) of seven residents reviewed. Specifically, Resident #3 was touched inappropriately by Resident #4, and Resident #1 with a history of wandering into other resident's rooms, was found partially clothed in Resident #2's bed. A physical assessment revealed possible trauma. Resident #1 was transferred to the hospital for a sexual assault assessment, which revealed Resident #1 had a genital wall tear and was treated [MEDICATION NAME] for [MEDICAL CONDITION] (STD). This resulted in actual harm to Resident #1 that is not immediate jeopardy. The findings are: A facility policy and procedure (P&P) titled Abuse Prevention, Investigation and Reporting dated 10/2015 defined sexual abuse as sexual harassment, sexual coercion, or sexual assault. Signs of sexual abuse include but are not limited to: bruising around genital area, bruising on inner thighs, unexplained vaginal bleeding, and torn stained undergarments. A facility P&P titled, Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 10/2019, documented the facility is to provide residents with an environment that is free from abuse. Methods for prevention of abuse are to assess, care plan, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. A facility P&P titled, 1:1 Supervision, revised 10/2019, documented 1:1 supervision requires assigned staff members to visualize the resident at all times and additional staff must be assigned by the nurse to cover for the primary assigned staff member's breaks. The purpose of 1:1 supervision is to increase safeguards for residents who are a risk to self and others. 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 1/18/21 documented the resident had severe cognitive impairment. A Physician History and Physical dated 10/16/20 documented Resident #1 had advanced dementia, significant lack of insight and understanding, lacked capacity (for medical decision making). Staff should provide a safe and caring environment. The current Closet Care Plan (guide used by staff to provide care) dated 3/19/21 documented Resident #1 was independent with ambulation and wandered without purpose. Resident #1's Comprehensive Care Plan (CCP) with dated of 3/22/21 documented the resident had dementia and was unable to be educated. The CCP did not address Resident #1 wandering into other resident's rooms. Resident #2 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had moderate cognitive impairment. The current Closet Care Plan dated 3/19/21 documented Resident #2 was independent for bed mobility and to remind resident to call staff if other residents upset him. Resident #2's Comprehensive Care Plan dated 1/8/21 documented behavioral symptoms. Interventions included to identify negative behaviors; set expectations; document behavior and monitor impending violent behavior. The facility's Resident Incident Report initiated on 3/20/21 at 1:35 AM, documented Licensed Practical Nurse (LPN) #2 found Resident #1 in Resident #2's bed not wearing pants or undergarments on 3/20/21 at 1:35 AM. Resident #2 wore no shirt, no pants or underwear. Registered Nurse (RN) #6 Supervisor was notified. Resident #1 was immediately removed from the bed and provided a brief and pants. LPN #2 assisted Resident #1 to the nurse's station with 1:1 supervision. Resident #1 had a linear (straight line) spot of blood in brief upon RN assessment. Resident #1 was unable to comment due to impaired cognition. The Nurse Practitioner (NP) #1 was notified at 3:00 AM. Resident #1 was transferred to the emergency room (ER) for evaluation at 4:05 AM. Emergency Department ED-Provider Report dated 3/20/21 at 4:42 AM documented Resident #1 had a history of [REDACTED]. Blood was noted in Resident #1's brief and caused concern for sexual assault. Resident #1 didn't remember the incident and was referred to the Sexual Assault Nurse Examiner (SANE). The Legal Guardian was notified and a 2-person consent received for SANE evaluation. The Legal Guardian agreed to a sexual assault collection kit, [MEDICATION NAME] treatment for [REDACTED]. SANE evaluation revealed 0.5 cm (centimeter) tear in the right lateral genital wall with some microscopic (small) bleeding and petechiae (brown-purple spots due to bleeding under the skin- caused by trauma). Resident #1 was discharged back to the facility on [DATE] at 7:15 AM. Review of the facility's surveillance video footage on 4/9/21 at 9:21 AM, revealed on 3/19/21 at 10:15 PM Resident #1 was ambulating in the hallway wearing shoes, pants, and a shirt, and entered Resident #2's room. At 1:30 AM (3/20/21) LPN #2 entered Resident #2's room. At 1:31 AM, LPN #2 was seen exiting the room to gather a brief and re-entered the room at 1:31 AM. At 1:34 AM, LPN #2 escorted Resident #1 out of Resident #2 room. Resident #1 had remained in Resident #2's room for 3 hours and 15 minutes. The video footage also revealed CNA #4 was sitting at the nurses' station from 11:00 PM to 1:30 AM (3/20/21). During an interview on 4/9/21 at 8:43 AM, RN #6 Nursing Supervisor, stated per the surveillance video on 3/20/21, Resident #1 was discovered in #2's bed partially clothed. RN #6 stated he performed a visual skin check with assistance of a female nurse and a two-inch linear line of fresh blood was noted in Resident #1's brief. RN #6 reported the incident to the Operations Manager (the Administrator on call) at 1:45 AM and notified the facility police at 2:30 AM and a report was filed. RN #6 stated they were concerned of possible trauma, after observing fresh blood in the brief. They notified NP #1 on 3/20/21 at 3:30 AM and NP #1 agreed to send Resident #1 to the ER for evaluation for possible sexual assault. During an interview on 4/9/21 at 9:58 AM, LPN #2 stated she entered Resident #2's room at 1:30 AM and found Resident #1 in Resident #2's bed. LPN #2 pulled the sheet down; Resident #1 had no pants or brief on, and Resident #2 was covered with a sheet from the waist down. LPN #2 called the RN Nursing Supervisor. LPN #2 asked Resident #2 what had happened, Resident #2 stated, What do you think happened between two adults?. LPN #2 stated it was not unusual to find Resident #1 in other resident's beds but never without any clothes on. LPN #2 stated they were concerned that a sexual assault may have taken place. LPN #2 stated Certified Nurse Aide (CNA) #4 was responsible for walking rounds at the beginning of the shift on 3/19/21 to account for all residents but did not conduct rounds according to the surveillance video. If rounds were completed, Resident #1 would have been found sooner. During an interview on 4/9/21 at 10:01 AM, the Operations Manager stated the RN Nursing Supervisor called to report the incident at 1:45 AM. The Operations Manager stated CNA #4 should have conducted rounds at the beginning of the 11:00 PM -7:00 AM shift to account for all residents. The surveillance video revealed CNA #4 did not do rounds, and falsely claimed she had done so by her written statement. During a telephone interview on 4/9/21 at 11:10 AM, the hospital ER SANE (RN) #7 stated she examined Resident #1 using the rape kit after consent from Resident #1's Legal Guardian on 3/20/21. The findings of the sexual assault exam revealed a 0.5 cm tear on the inside genitalia, which indicated penetration. The SANE RN #7 stated the report was released to the local police department and Resident #1 had no additional physical injuries and was unable to recall the event. During an interview on 4/9/21 at 1:24 PM, Resident #1 was pleasantly confused, made non-sensical statements, and was unable to participate in an interview. During interview on 4/9/21 at 4:04 PM, Resident #2 stated they recently had their room changed due to an incident that occurred. Resident #2 stated they told LPN #2 they would not have had sexual contact with Resident #1 if they knew Resident #1 had dementia. Resident #2 wouldn't specify what sexual contact occurred with Resident #1 and became resistant to further interview. During an interview on 4/9/21 at 1:41 PM, CNA #2 stated Resident #1 had dementia, wandered into rooms daily and was redirected by staff. During an interview on 4/9/21 at 1:54 PM, CNA #3 stated Resident #1 wandered daily and often found Resident #1 in other resident's beds. During an interview on 4/9/21 at 2:10 PM, RN Team Leader #3 stated Resident #1 had dementia, was affectionate towards other residents and staff. Resident #1 previously shared a room with their spouse and often slept in the same bed. The wandering behaviors had increased after their spouse passed away. RN #3 stated when Resident #1 was found in another bed, redirection was provided. An attempt to contact CNA #4 on 4/12/21 at 9:16 AM was unsuccessful. During a telephone interview on 4/12/21 at 11:00 AM, Social Worker (SW) #1 stated Resident #2 occasionally showed aggressive behaviors towards staff and other residents. SW #1 stated the injury Resident #1 sustained caused concern that Resident #1 and #2 had a sexual encounter. SW #1 stated Resident #1 didn't understand and wasn't aware of what happened. During a telephone interview on 4/12/21 at 1:46 PM, NP #1 stated she was notified by the RN Nursing Supervisor on 3/20/21 at 3:30 AM they were concerned that a sexual assault may have taken place between Resident #1 and Resident #2. NP #1 stated the blood in the brief indicated recent trauma and staff were concerned. NP #1 stated forceful intercourse would lead to a tear in the genital wall and given Resident #1's [DIAGNOSES REDACTED]. During a telephone interview on 4/12/21 at 2:45 PM, the Director of Nurses, (DON) stated CNA #4 was responsible to do rounding at the beginning of her shift at 11:00 PM to account for all residents. The DON stated per surveillance video, CNA #4 never conducted rounds. During an interview on 4/12/21 at 3:23 PM, the Administrator stated she was informed of the incident at 7:00 AM on 3/20/21. The RN Supervisor noted blood in Resident #1's brief, which warranted some concern of injury and the resident was sent to the ER. The Nursing Supervisor reviewed the surveillance video that showed Resident #1 entered Resident #2's room at 10:15 PM. The Administrator stated CNA #4 never conducted rounds at the beginning of the shift and provided a false statement. The Administrator stated it was unfortunate the incident occurred and any tear in the skin was considered an injury, but the cause was unknown. 2. Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 2/23/21 documented the resident rarely/never understands and was sometimes understood. Review of the Determination of Capacity for Resident #3 signed and dated by a physician on 9/6/17 documented Resident #3 had no capacity to make healthcare decisions. Review of the Closet Care Plan (guide for staff to provide care) for Resident #3, last updated 2/12/21, documented Resident #3 required total assistance with personal care, bathing, feeding, and toileting. Resident #3 ambulates independently and wanders without purpose. Observation of Resident #3 on 3/18/21 at 12:50 PM revealed the resident was awake in their room, sitting on their bed. Resident #3 did not respond to this Surveyor's greeting and was unable to be interviewed. Resident #4 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident understands and was understood. Review of the Comprehensive Care Plan for Resident #4, updated and reviewed by the facility 8/17/20, documented the resident had a history of [REDACTED]. Review of the Closet Care Plan for Resident #4, updated and reviewed by the facility 12/9/20, documented behavioral interventions included report behavior changes, report altercations, redirect if disrobing or agitated, distract if inappropriate, supervised activities and 1:1 day shift, 1:1 evening shift and 1:1 night shift. Additionally, the Closet Care Plan included the following aggression intervention comments: 1:1, no physical contact with female caregivers, may have a Certified Nurse Aide (CNA) outside closed bedroom door for 1:1, no physical barriers are to be between resident and supervising staff, other than bedroom door. Review of the Social Work Behavioral Care Plan for Resident #4, dated 2/3/21, documented Resident #4 exhibited resistive behaviors directed at staff, other residents, family members, self, and visitors. This was evidenced by history of threats, history of violence, bullying, pacing, clenching fists, taking a threatening stance, using foul language, name calling, throwing objects, verbal outbursts, inappropriate sexual gestures, and scratching/biting/spitting. The document also indicates Resident #4 is unpredictable and a level one sex offender. Review of the Resident Incident Report for Resident #4, dated 3/5/21, documented on that date at 1:40 PM, Resident #4 was found to grab the privates of another resident while standing in the main dining room. Resident #4's comment after the incident was, I was just kidding around. Review of the Resident Incident Report for Resident #3, dated 3/5/21, documented on that date at 1:40 PM, Resident #3 was wandering the unit and LPN (Licensed Practical Nurse) #1 witnessed and interrupted the inappropriate touching of Resident #4 touching the genitalia area of Resident #3, all clothing intact. According to the Resident Incident Report, Resident #3 was unable to comment after the incident due to dementia and [MEDICAL CONDITION]. Review of a Witness Statement Form, signed by CNA #1 on 3/5/21, documented CNA #1 was assigned to Resident #4. CNA #1 went to use the bathroom, and that was when the incident occurred. Review of Nursing Unit Work/Break Schedule dated 3/5/21 documented CNA #1 was assigned to 1:1 supervision for Resident #4 during the 7:00 AM to 3:00 PM shift. During a telephone interview on 4/6/21 at 10:18 AM, CNA #1 stated she was assigned to 1:1 with Resident #4 the day of the incident. CNA #1 stated Resident #4 was 1:1 because of their behavior, they are sexual to employees, aggressive, have mood swings, and sometimes can get into problems with other residents. CNA #1 stated she had an extreme bathroom emergency and ran to the bathroom. She further stated she thought she told the nurse that she was going to the bathroom but was not 100% sure. She ran into the bathroom and was not gone more than five minutes. CNA #1 stated when she works on that unit, staff make sure they cover their resident when someone needed to walk away. CNA #1 stated she knew she should not have left the resident alone and normally she would tell another staff member before leaving for the bathroom. During an interview on 3/18/21 at 12:12 PM, LPN #1 stated she was coming back down the hall, when she saw Resident #4 touching Resident #3 in the private area over clothes. She stated she intervened and told Resident #4 to stop and redirected Resident #3 out of the area. LPN #1 further stated Resident #4 told her, I'm not even doing nothing, and this is what teenage boys do. Additionally, LPN #1 stated Resident #4 is 1:1 24 hours per day, and CNA #1 was assigned to be their 1:1 that day. CNA #1 was not present when the incident occurred. During an interview on 3/18/21 at 11:55 AM, the (Registered Nurse) RN Team Leader #1 stated Resident #4 has impulse control problems and a history of sexual contact with other residents and staff. The RN #1 added that after the incident, Resident #4 stated, It's locker room stuff, it's what guys do. RN #1 stated that Resident #3 has early onset dementia and is non-verbal and did not appear to have understood what occurred. RN #1 added that Resident #4 has been 1:1 for more than two years straight and at the time of the incident, CNA #1 was assigned to them. After the incident, CNA #1 told him that she stepped away to go to the bathroom. CNA #1 should have found someone to sit with Resident #4 for a few minutes. RN #1 stated to his knowledge, CNA #1 did not do that. For the 1:1 supervision assignment, they don't schedule breaks, they just step in for each other. During an interview on 3/18/21 at 1:41 PM, the Director of Nurses (DON) stated CNA #1 should have called someone to relieve her to cover the 1:1 while she was gone and she does not know if CNA #1 asked to leave on a break before she left. The DON further stated there was not an official schedule for breaks of staff who were doing 1:1 supervision, and it had to be an open situation due to the nature of the unit. During an interview on 3/18/21 at 1:45 PM, the Assistant Director of Nursing (ADON) stated CNA #1 said she had yelled out, I'm going to the bathroom and she went to the bathroom. The ADON further stated she asked CNA #1 if she made sure if the nurse heard her, and she replied, I don't know if they did or not. During an interview on 4/5/21 at 2:15 PM, the Operations Manager stated Resident #4 is on 1:1 supervision for numerous reasons, including physical and sexual inappropriateness. The Operations Manager also stated 1:1 supervision means watching a resident 24 hours per day. 415.4(b)(1)(i) | Plan of Correction: ApprovedMay 17, 2021 Please Note: The Plan of Correction serves as a written allegation of compliance: Corrective Action To ensure the residents are free from abuse, neglect, misappropriation of resident property & exploitation. This includes but is not limited to freedom of corporal punishment, involuntary seclusion & any physical or chemical restraint not required to treat the residents medical symptoms. 1) As noted in finding: Resident #3 was touched inappropriately by Resident #4. Resident #1 (with history of wandering) was found partially clothed in Resident #2?s bed. 2) To ensure all residents are free from abuse, neglect & exploitation the following will be implemented: A) A consultant who is not employed at the facility has been hired. The Consultant implemented a Directed Plan of Correction/and Directed In-services. The outside consultant,director of nursing, and administrator reviewed shift routine policy, and policy was deemed appropriate. All nursing staff will be in-serviced on: resident abuse, shift routines, types of resident abuse, prevention of resident Abuse, and reporting resident abuse. All nursing staff including (All, RNS, LPNS and CNAS) will attending the mandatory in-service on Resident Abuse.The in-service will be mandatory for all nursing staff on all 3 shifts. All nursing staff must sign off they have attended the mandatory resident abuse in-service. B.Audits will be completed by Director of Nursing/Assistant Director of Nursing to ensure all nursing staff have attended the in-services. Audits for shift routine rounds will be completed 3x per week ending 5/30/21. Audits for shift routine rounds will then be completed 2x per week ending on 6/12/2021 All audits will be reviewed at the Quality Assurance meeting.The Director of Nursing will assume full responsibility for the correction of F600. 3.The Consultant, Director of Nursing, and Administrator reviewed one to one supervision policy and policy has be deemed appropriate. All nursing staff including (RNs, LPNs,and CNAs) will be in-serviced by our consultant on the one to one policy. All in-services are mandatory for all nursing staff on all 3 shifts. The Director of Nursing/Assistant Director of Nursing will ensure all Nursing Staff have attended the in-services. Audits to ensure one to one has assigned relief person will be completed 3x per week ending 5/30/2021. Audits to ensure one to one staff has assigned relief will then be completed 2x per week ending on 6/12/2021. All audits will be reviewed at monthly Quality Assurance meeting x 6 months. The Director of Nursing will assume responsibility for F600. 4. To ensure all residents are free from abuse, neglect, & Exploitation the following will be implemented: 1.Hired the services of a consultant, not employed at the facility, to develop and implement a plan of correction. 2.Convene the facility's Quality Assurance Committee to examine the deficiencies cited under Fed. F-0600-483.12(a) (1)- Free From Abuse and Neglect S-S=G. 3.The consultant completed a mandatory directed in-service program to all nursing staff. 4.Audits will be completed to ensure all nursing staff attended mandatory directed in-service. 5. Audits will be brought to Quality Assurance Meeting to be reviewed. 6.Care Plans on residents #1,#2,#3,& #4 have been reviewed and will be monitored. |