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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: November 3, 2022
Corrected date: December 1, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY 595) the facility failed to protect the resident's(s') right to be free from Sexual abuse, potential physical and psychosocial harm by a staff member. This was evident for one (Resident #1) of 3 residents reviewed for Sexual Abuse. Specifically, Certified Nurse's Assistant (CNA) #1 witnessed Recreation Aide (RA) #1 in Resident #1's bed lying behind the resident on their left side and appeared that RA #1 was having sexual intercourse with Resident #1. CNA #1 did not intervene to protect the resident and left Resident #1 alone with RA #1 in the room for approximately 3 minutes failing to ensure the resident was safe and free from further abuse. Additionally, the facility failed to protect all other residents by allowing the alleged perpetrator (RA #1) access to all 191 residents in the facility. The facility did not immediately remove RA #1 from the facility's premises. This resulted in actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy to resident health and safety. This had the potential to affect all 191 residents in the facility. The finding is: The Facility's policy titled Abuse Prohibition and Prevention dated 6/24/2022 documented each resident of the facility shall be free from abuse, neglect, mistreatment, and exploitation and misappropriation of property. Abuse shall include physical harm, mental anguish, verbal abuse, sexual abuse, and involuntary seclusion of any source. Sexual abuse was defined as non-consensual intrusion or penetration, touching intimate body parts or the clothing covering intimate body parts, examination, or treatment of [REDACTED]. During the investigation, the Resident must be protected from additional harm. It is the facility's policy that the individual (s) named and/or involved in any alleged abuse be removed from the facility setting (including grounds) immediately and suspended until such abuse has been ruled out or verified for the duration of the investigation to protect the Resident from any type of retaliation or further abuse. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS-an assessment tool) dated 10/12/2022 documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. The Resident was dependent with 2 staff members for bed mobility. The Comprehensive Care Plan (CCP) dated 6/1/2016 and updated on 10/30/2022 titled Potential for Victimization documented that Resident #1 was at risk for victimization related to presence of behavioral, functional, cognitive or psycho-social issues and [DIAGNOSES REDACTED]. The Nurse's Progress Notes (NPN) dated 10/30/2022 at 10:31 PM documented at approximately 4:30 PM, Certified Nursing Assistant CNA #1 reported to Registered Nurse Supervisor # 1 (RNS #1) that they observed another person in Resident#1's bed. As CNA #1 approached Resident'#1s bed they (CNA#1) saw the Recreation Aide (RA) #1 in the bed lying behind the Resident#1 and (both Resident #1 and RA#1 were lying on their left sides) and that RA #1 had their right leg over the resident. RA #1 pants were unzipped, and they were having sexual intercourse with Resident #1. Resident#1 was transferred to the hospital for an assessment and rape examination. The Emergency Medical Services (EMS) report dated 10/30/2022 documented EMS was dispatched to the facility for a reported sexual assault. Nursing home staff stated that a recreation aide was found with their pants down behind a patient in the patient' room between 3:30 PM and 4:30 PM on 10/30/2022. The emergency room Department Discharge Instructions dated 10/30/2022 at 7:23 PM documented that Resident#1 was evaluated due to a report of Sexual Assault. The facility's investigative summary undated documented on 10/30/2022, at approximately 3:50 PM CNA #1 was returning to Resident #1's room and observed Recreation Aide (RA #1) lying behind the resident. The resident was on their left side and RA #1 was also on their left side both facing the window. CNA #1 reported that resident's brief was twisted to the side of hip bone, however CNA #1 could not see between RA #1 and resident's backside. CNA #1 reported that RA #1's black pants and shoes were on the bed, the pants were open in the front and pulled down along with RA #1's underwear exposing the butt crack. RA #1 was moving back and forth thrusting motion like having sex and RA #1's right leg was on top of resident's right leg, RA #1's left leg (knee) was on the bed, but their foot was partially hanging over the side of the bed. CNA #1 reported that they exclaimed, Jesus wept then RA #1 turned to look at CNA #1 and did not say anything. CNA #1 reported that they felt panic and immediately called out for help and left. CNA #1 stated that at the same time of the occurrence, a code blue had been called on another unit and most staff had responded to help. CNA #1 reported to LPN #1 what they observed. Licensed Practical Nurse (LPN) #1 and CNA #1 went to resident's room and saw the resident's blankets had been pulled up neatly. And the resident was facing the window (side lying). LPN #1 and CNA #1 lifted the blanket and moved the incontinent brief slightly to check for blood but did not want to disturb potential evidence. RNS #1 was notified and reported to Director of Nursing (DON) that CNA #1 as unable to locate RA#1 from 4:30 PM through 6:00 PM. then at approximately 6:15 PM on 10/30/2022, Assistant Director of Nursing (ADON) reported to DON that RA #1 was at the reception desk and was brought to the police station for questioning. The facility's investigative report also documented that RA #1 was scheduled to work on 10/30/2022 between 9:30 AM to 7:30 PM and that their break schedule was between 5:00 PM to 5:30 PM. Additionally, the investigative report documented that RA #1 was not assigned to Resident #1 for a one to one visit or to provide ADL assistance. The facility concluded that there was credible evidence of abuse. Resident #1 was observed on 11/1/2022 at 2:00 PM and 11/3/2022 at 10:39 AM. Resident is non-verbal and did not respond when name was called. A review of the video surveillances conducted on 11/1/2022 at 2:40 PM with Maintenance Director, ADON and Administrator revealed that on 10/30/2022 at: 3:48:26 PM- RA #1 walked down the Unit B hallway, was looking in each room, looked at Resident #1's room and went pass Resident #1's room and went out of video surveillance 3:48:46 PM RA #1 reappeared in the video frame and entered into Resident#1's room. 3:50:31 PM CNA #1 entered Resident #1's room. 3:50:44 PM CNA #1 exited Resident #1's room and walked down the hallway and out of video surveillance. 3:53:01 PM RA #1 exited Resident #1's room and walked the hallway and out of video surveillance. 3:53:57 PM RA #1 passed by Unit B nurses' station and appeared to have something in their hand and opened the bathroom door near the station and quickly closes it. Then went down a hallway and out of video surveillance. 3:54:23 PM RA#1 entered Unit C (same floor as Unit B) passed the nurses' station and went out of video surveillance. 3:56:18 PM RA#1 was seen at front desk and picked up two boxes and left -went out of video surveillance. 3:57:11 PM RA #1 was holding two boxes by elevators and assisted Resident #2 with their rolling walker and went out of video surveillance with Resident #2. 4:01:59 PM RA#1 carrying boxes and with Resident #2 at the elevator. 4:04:36 PM RA #1 was at the elevator with RA #2 and went out of video surveillance 4:13:10 PM RA#1 was seen in the lobby at the front desk and exited the building. 6:10:14 PM RA #1 re-entered into the building and sat at the front desk. 6:12 PM-ADON approached RA#1 sitting at front desk and went into the DON's office. 6:21:58PM RA #1 was handcuffed by two police officers and exited the building at 6:22 PM. During an interview with CNA #1 on 11/1/2022 at 4:59 PM they stated on 10/30/2022 they worked from 7:00 AM to 11:00 PM and was assigned to Resident #1. CNA #1 checked on the resident at approximately 2:00 PM and left the resident wearing a blouse and incontinent pad with no bottom and was covered with a flat sheet and blanket lying on their back. A code blue was called on another unit at approximately 3:30 PM. CNA #1 went to check the resident at approximately 3:50 PM and saw a shoe, black pants, a leg over resident's legs moving and thought it was another resident. CNA #1 stated when they were about 6-7 feet away, they could see that it was not a resident. CNA #1 saw someone's butt crack, their pants were undone, the resident was on their side, and the side of the resident's incontinence brief was twisted. CNA #1 said they screamed Jesus wept. The guy that was in the bed turned their face around and they saw it was RA #1. CNA #1 said they could see RA #1's leg over the resident's leg moving back and forth but did not see RA #1's penis. RA #1's right leg was over Resident's leg and the blanket and sheet were down at the foot of the bed. RA #1's pants were undone. CNA #1 stated they knew they should have stayed with the resident and should have put the call light on. CNA #1 reported that they told CNA#2 and CNA#3 what they saw because they could not locate LPN #1, who was responding to the code blue. CNA #1 informed LPN #1 and they observed the resident lying on their side and was covered. LPN #1 checked the resident's brief and directed them to report the incident to RNS #1. During an interview with CNA #2 on 11/2/2022 at 8:43 AM they stated that on 10/30/2022 they worked 7:00 AM-11:00 PM. CNA #2 stated that CNA #1 informed them they saw RA #1 having sex with Resident #1. CNA #2 stated they went to check the resident and did not see RA #1 in the room. CNA #2 left the residents room to find LPN #1. During an interview with Registered Nurse Supervisor (RNS) #1 on 11/2/2022 at 11:43 AM RNS#1 stated that on 10/30/2022 a 3:45 PM there was an emergency stat code. The LPNs responded to the stat until about 4:15 PM. RNS #1 stated that CNA#1 described that they saw RA#1 having sexual intercourse with Resident#1. RNS #1 asked CNA #1 for a statement and asked the whereabouts of RA #1. RNS #1 called the ADON then called the police and reported a possible sexual assault involving a staff and a resident. RNS #1 immediately activated a page to locate RA #1. LPN #1 informed RNS #1 that they checked the resident, and their incontinence brief was closed and there was no evidence of any trauma or bleeding and the incontinence brief was dry. RNS #1 stated they could not really assess the incontinent brief because they did not want to touch the resident. RNS #1 stated the resident appeared to have no signs and symptoms of pain or discomfort. Police officers (PO) arrived but they could not locate RA #1. When RA #1 walked back into the building at approximately 6:00 PM, the police arrested RA. RNS #1 stated CNA #1 should not have left Resident #1's room with RA #1 still in there. RNS #1 stated it is not the protocol to leave the resident alone with the perpetrator in the room. During an interview with LPN #1 on 11/2/2022 at 12:41 PM stated on 10/30/20 that they worked between 7AM to 7:40 PM. LPN #1 responded to a code blue on another unit around 3:00 PM. CNA #1 told LPN #1 that they saw RA #1 was in bed with the resident. CNA #1 stated they did not know the whereabouts of RA#1. LPN #1 went to resident's room with LPN #2, CNA #1, and CNA #3. LPN #1 saw the resident was lying on their left side and was covered with their blanket. LPN #1 looked inside the residents incontinent brief and did not go any further because they did not want to disturb any possible evidence. The resident was awake and did not show signs and symptoms of discomfort. LPN #1 paged RNS #1 and told another CNA #1 to make sure no one comes on the unit, and to look out for RA #1. LPN #1 and CNA #1 went to RNS #1's office and CNA #1 reported the incident to RNS #1. RNS #1 came to the unit to assess the resident. LPN #1 stated they did not have in-service on finding someone in bed with someone and this was a different situation. During an interview with the Director of Recreation (DOR) on 11/2/2022 at 1:09 PM they stated that RA #1 worked on 10/30/2022 from 9:30 AM to 3:30 PM. RA #1 and was not assigned to do any 1:1 activity to Resident #1 or any resident. RA #1 goes on break from 5-5:30 PM to cover the break of the security guard or receptionist. RA #1 was assigned to help units A and B in the dining rooms to keep resident's safe. DOR was made aware of the incident at 6PM on 10/30/2022. DOR was informed that RA #1 was involved in a sexual assault and was arrested by the Police and was terminated. During an interview with the DON on 11/2/2022 at 3:14 PM they stated that ADON told them that CNA #1 witnessed RA #1 in the resident's room lying in the bed with resident#1 with their pants down. DON instructed ADON to call 911. DON stated that when they arrived at the facility at 5:25 PM the police were already present. ADON and Maintenance Director reviewed the video footage. DON stated RA #1 entered resident's room after an immediate emergency situation call was announced. The DON stated that the CNA #1 told them they left the room to look for LPN #1. The ADON informed them that they saw RA #1 at the reception desk. The DON conducted an interview with RA #1 who stated, I was sitting, and I know it looks bad, I positioned the resident. I sat on resident's bed, and I was on my phone and sent a text that is all. The DON stated, they asked the RA #1 if it was necessary to sit on resident's bed and text and RA #1 stated I know it looks bad. The DON stated RA #1 was profusely and profoundly sweating. The Suffolk County Police Detective arrived and took RA #1 custody after RA #1 wrote their statement. DON stated the staff are expected to stay with the resident if they witness an abuse. The staff can always pull a call bell, or emergency bell in the restroom. DON stated the video surveillance appears RA #1 went into the room at 3:48 PM and CNA #1 went in at 3:50 PM. Then someone left the room at 3:52 PM. DON stated they did not know who left the room. The resident was sent to the hospital for rape kit and the facility did not have result of rape kit. The facility changed the secure door code and terminated RA #1 on 10/30/2022 and called to Criminal History Record Check (CHRC). Resident #1 was assessed for psychological service. An updated intervention was initiated have a male staff member provide them care. DON found out later after viewing the video surveillance that RA #1 interacted with another resident (Resident #2) by assisting them to the elevator. RA #1 came back to the facility and was relieving a security guard when they were told RA #1 had left and thought the danger is gone. During an interview with ADON on 11/2/2022 at 7:24 PM they stated that on 10/30/2022 they were called by RNS #1 at approximately 4:30 PM. The ADON stated that CNA #1 walked into Resident #1's room and observed RA #1 their pants down behind the resident. ADON was in the building at 5:12 PM and the RNS #1 called the police around 5:15 PM. The ADON stated that the DON arrived at the facility by 5:20 PM-5:25 PM. The ADON stated when they came out from RNS office, they saw RA #1 behind the reception desk. ADON stated the staff should have stayed in the resident's room and protected the resident. The ADON reviewed the video surveillance with maintenance, and it showed RA #1 walking around the facility and had contact with another resident. The ADON stated that the staff should have known RA #1's whereabouts and place RA #1 in a contained room with supervision. CNA #1 could use the call bell in the room and the emergency call bell in the bathroom. In a reasonable person standard, ADON stated that they would feel violated if they were the resident, especially since the resident could not express themselves. The family was notified and was weepy on the phone. During an interview with the Administrator (Adm) on 11/2/2022 at 8:57 PM they stated that they were notified that RA #1 was found by CNA #1 lying in bed with Resident #1 and that the RA #1's legs were over Resident #1's legs. The Adm stated that CNA #1 stated they saw RA #1's feet and legs in motion like having sex with the resident. Adm said they went to Maintenance and viewed the cameras. They said they arrived in the building around 6:40 PM and RA #1 was already taken into police custody. Adm stated that CNA #1 should have never left Resident #1's room. The Administrator stated the staff need education on how to deal with situation such as resident's abuse. The Administrator stated that the RA #1 should have been contained in one area until the police arrived. The family was very upset and distraught. The facility concluded that the situation could have been handled differently like staying with the resident. 10NYCRR 415.4(b)(1)(i) | Plan of Correction: ApprovedNovember 30, 2022 Plan of correction not approved or not required |