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Scope: Isolated
Severity: Actual harm has occurred
Citation date: April 19, 2022
Corrected date: May 18, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Abbreviated survey (NY 320) completed on 4/19/2022, the Facility did not ensure residents rights to be free from sexual abuse. This was identified for 2 (Resident #1 and # 2) of 4 residents reviewed for abuse. Specifically, Certified Nursing Assistant (CNA) #1 inappropriately touched Resident #1 and Resident #2 while providing routine care. This resulted in actual psychosocial harm to Resident #2 that was not an immediate jeopardy. The Findings are: The Abuse policy dated 2/22/2021 documented that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation, and misappropriation of property. Residents will not be subjected to abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, contractors, and staff from other agencies, family members, legal guardians, resident representatives, friends, or other individuals. The Policy definition of sexual abuse was the non -consenting contact of any kind and included but was not limited to sexual harassment, sexual coercion, or sexual assault. 1) Resident#1 was admitted to the Facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated on 3/5/2022 documented the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating intact cognition. The MDS further documented that Resident#1 required extensive assistance with one person for dressing, extensive assistance with two persons for personal hygiene, two-person assistance for toileting, extensive assistance with two persons for bed mobility, and total dependence of two persons assistance for transfer. The MDS further documented that Resident #1 was always incontinent with bowel and bladder. A nursing progress note dated 3/5/2022 at 12:34 PM documented that Resident#1 was observed with increased confusion from baseline on admission. The Primary Care Physician ordered to transfer Resident#1 to Hospital for evaluation and emergency [MEDICAL TREATMENT] on 3/5/2022. The Facility Occurrence Investigation initiated on 3/8/2022 documented Resident#1's family notified the Facility on 3/8/2022 that Resident#1 reported that during care on 3/5/2022, their assigned male CNA, stuck their finger in Resident#1's rectum. The Occurrence Investigation report dated 3/8/2022 documented that the Facility started an investigation upon Resident#1's family member's notification about CNA#1. The Facility conducted an interview with all residents (7) assigned to CNA#1 on 3/5/2022. During the investigation Resident#2 was identified with the same sexual abuse allegation that CNA#1 inserted their finger in Resident#2's rectum. Attempts were made to contact Resident#2 for an interview but was unsuccessful. 2) Resident#2 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment initiated on 2/7/2022 documented the resident's Brief Interview for Mental Status (BIMS) score was 14 indicates intact cognition. The resident required extensive assistance with two people for bed mobility, transfer, and toileting. Resident#2 required extensive assistance of one staff member for personal hygiene. The Occurrence Investigation Summary completed on 3/10/2022 documented the investigation concluded that CNA#1 did not completely admit that the allegations were truthful. However, Resident#1 and Resident#2, whose BIMS scores were between 14-15, came forward having the same allegations and based on CNA#1 statement that 'CNA#1 may have stuck up their finger to Resident#2 buttocks , through this investigation, the Facility believes that possible abuse may have occurred. CNA#1 had been terminated from employment at the Facility. Resident#2 was interviewed on 3/17/2022 at 11:30 AM and stated on 3/5/2022 in the morning, CNA#1 came into their room to provide personal hygiene. Resident#2 stated CNA#1 turned off the lights and placed a hot wet towel between their legs while laying down on their back. Resident#2 stated CNA#1 began to massage between their legs and inner thighs. Resident#2 stated that no caregiver had ever done that type of a care before. Resident#2 stated that CNA#1 placed a hot towel on their chest. Resident#2 stated that CNA#1 continued to massage between their legs and thighs and slowly moved to their buttocks. Resident#2 stated CNA#1 separated their butt cheeks and started massaging the buttocks and rectum area. Resident#2 stated that CNA#1 asked permission to put some A and D ointment on their finger to grease their body. Resident#2 stated they permitted CNA#1 since they did not think anything of it. Resident#2 stated that CNA#1 massaged Resident#2's back with the ointment. Resident#2 stated CNA#1 then put the ointment on their rectum area and inserted their finger inside their rectum. Resident#2 stated that after 6 to 8 seconds they realized this care was not part of a bed bath, and they had pain. Resident#2 stated they informed CNA#1 they had pain, and CNA#1 stopped and took their finger out. Resident#2 stated that CNA#1 completed their bed bath and helped them get dressed. Resident#2 further stated they were surprised and tried to comprehend what happened. Resident#2 stated they have a family, and they could not face their family due to the shame of the incident. Resident #2 was observed during the interview crying with tears dripping from their cheeks and shaking. Resident#2 was observed grabbing the wheelchair armrests and squeezing them. Resident#2 was observed making a fist and waving their hands and stated, this should have not happened. Resident#2 stated they are ashamed. Resident#2 stated it was their fault this happened, and they should have protected themselves. Resident#2 stated they were ashamed and embarrassed to report the incident to the Facility until they were interviewed. The Director of Nursing (DNS) was interviewed on 3/17/2022 at 9:40 AM stated they received a call on 3/8/2022 at approximately 11:00 AM from Resident#1's family member to report a sexual abuse allegation that occurred on 3/5/2022 during 7:00 AM to 3 PM shift, involving CNA#1 and Resident#1. The DNS stated that CNA#1 was interviewed and was sent home around 11:05 AM on 3/8/2022. The DNS further stated that CNA #1 was instructed not to return to work until the sexual allegation investigation was completed. The DNS stated that CNA#1 admitted that they may have put their finger in Resident #2 rectum. The DNS further stated that the Director of Social Worker (SW#1) interviewed seven (7) residents assigned to CNA#1 on 3/5/2022 from 7:00 AM to 3:00 PM hours. During investigation and interviews of 7 residents who were assigned to CNA#1 on 3/5/2022 morning, Resident#2 was identified with the same allegation. The Director of Social Work (SW#1) was interviewed on 3/17/2022 at 11:23 AM and stated they were made aware of the sexual abuse allegation by the DNS on 3/8/2022 at 11 AM. SW#1 further stated that the DNS initiated the investigation for this allegation on 3/8/2022 at 11:00 AM. SW#1 further stated that Resident#1 did not notify any staff regarding the sexual abuse allegation. SW#1 stated they interviewed seven residents, and Resident#2 was identified as having a similar sexual allegation. SW#1 stated that during the interview with Resident#2, they appeared uncomfortable, shy, and reserved. SW#1 stated that Resident#2 stated that CNA#1 placed a hot towel on their chest. CNA#1 continued to massage between their legs and thighs and slowly move to their buttocks. Resident#2 stated that CNA#1 separated their butt cheeks and started massaging the buttocks and rectum area. Resident#2 stated that CNA#1 asked permission to put some A and D ointment on their finger to grease their body. Resident#2 stated they permitted CNA#1 since they did not think anything of it. Resident#2 stated that CNA#1 massaged Resident#2 back with the ointment. Resident#2 stated CNA#1 put the ointment on their rectum area and inserted their finger inside their rectum. SW#1 stated they notified the Psychologist#1 and SW#2 regarding the sexual abuse allegation to initiate a consult with Resident#2. Registered Nurse (RN) RN#1 was interviewed on 3/19/2022 at 5:31 PM and stated that on 3/8/2022, the DNS directed RN#1 to perform a complete body assessment of Resident #2 as part of a sexual abuse investigation. RN#1 stated they found no skin changes, [MEDICAL CONDITION], bruises, or redness on Resident#2's body or rectum area. RN#1 stated that the resident reported that CNA#1 put their finger in their rectum. RN#1 stated that Resident#2 appeared to be upset. CNA#1 Personnel files revealed CNA#1 was an Agency employee contracted by the Facility. CNA#1 was in-service by the Facility on Sexual Harassment Policy and Procedure on 12/22/2021 prior to working at the Facility. CNA#1 was interviewed on 3/21/2022 and stated they had been CNA since (MONTH) 2021, and this Facility was their first CNA job. CNA# 1 further stated their regular shift was 11:00 PM to 7:00 AM, but they often work 7:00 AM to 3:00 PM as a floater CNA to help the Facility. CNA#1 stated they were assigned to Resident#1's care on 3/5/2022 on the 7 AM to 3 PM shift. CNA#1 stated that on 3/5/2022 morning, they made hot wet towels to take care of Resident#1's skin during a bed bath. CNA#1 stated Resident#1 did not like body massages on their buttocks because Resident#1 had a wound on their buttocks. CNA#1 stated they stopped massaging Resident#1 inner buttocks after Resident#1 informed CNA#1 they had pain to their buttocks. CNA#1 stated they completed the perineal hygiene task and put Resident#1's clothes on. CNA#1 stated that Resident#2 did not have a sore on their buttocks. CNA #1 stated they started to grease Resident#2 buttocks and their rectum area. CNA#1 stated that they applied ointment to lubricate Resident#2 rectum to help Resident#2 dry skin around their rectum. CNA#1 stated giving a hot wet towel massage and greasing Resident#2's skin would make the Resident feel better. CNA#1 stated they used ointment as a lubricant to massage Resident#2 rectum to release the dry skin. CNA#1 stated they pulled their finger out of Resident#2 buttocks after the resident informed them, they had pain. CNA#1 stated they applied grease to all residents' skins, including their buttocks and rectum since dry skin makes residents' bowel movements pass harder and more complex. The Administrator was interviewed on 3/21/2022 at 2:21 PM and stated they were in the building on 3/8/2022 around 6:00 PM. They stated they informed the Staffing Agency about the sexual abuse allegation and that CNA# 1 was terminated. Psychologist #1 was interviewed on 4/12/2022 at 2:01 PM and stated that prior to Resident#2 discharge from the facility they had a therapeutic session regarding Resident#2 sexual abuse trauma. Psychologist #1 stated that during the therapeutic session, Resident#2 started crying and told the Psychologist they did not how they would face their family members after the sexual abuse. Psychologist #1 stated that Resident#2 was very upset and cried throughout the session. Psychologist #1 stated that Resident#2 would be affected by this sexual abuse trauma for the rest of their life. CNA #1 was re-interviewed on 4/19/2022 at 12:39 PM and stated the Facility did not instruct CNA#1 to insert their finger into Resident#1 and Resident#2's rectum. CNA#1's description of the rectum was the entire buttocks, including the opening area where the feces came from. CNA#1 stated that sexual abuse was having sex or touching someone without their permission. CNA#1 further stated, God and Angels helped me taking care of Residents and helped my days and nights go smooth, easy, and fast. CNA#1 stated, God gave me a mission to help people. They had a special gift of knowledge to take care of people, and they can utilize it to assist residents in alleviating their bowel movements. 415.4(b) | Plan of Correction: ApprovedMay 9, 2022 1. a. Resident #1 no longer resides in the facility. b. Resident #2 no longer resides in the facility. c. CNA#1 was terminated. 2. a. All residents have the potential to be affected by the finding. b. The facility Director of Social Work (SW)/designee will interview all cognitively intact residents to identify any abuse/neglect or mistreatment. c. All cognitively impaired residents will be audited for S/S of abuse/neglect/mistreatment. Interviews and audits revealed no further complaints/allegations. 3. a. A review of the facility policy titled ìAbuseî was completed By the DON and Administrator, no changes necessary. b. All staff was re-educated on the facility Abuse Policy. c. All alert residents will be educated to report any S/S abuse/neglect/mistreatment immediately. 4. a. DON/Designee will conduct direct care observation audits for 15 CNAs randomly weekly X4 then monthly X3 to ensure no inappropriate touching behaviors or inappropriate conduct will occur. The results of the audits will be presented at the quarterly QA committee meeting for review and feedback. Responsible party: Director of Nursing |