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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: November 3, 2022
Corrected date: N/A
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 | Plan of Correction: ApprovedNovember 30, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Fed - F - 0600 - 483. 12(a)(1) - Free from Abuse, Neglect and Exploitation Directed Plan of Correction The facility obtained the services of a consultant, not employed by the facility, to develop and implement an acceptable directed plan of correction. The Quality Assurance (QA) Committee, at a minimum, addressed the following: A. Complete an assessment of the causative factors that may have contributed to the issues identified in each of the above deficiencies. 1. RA #1 employee records were reviewed for education and training on abuse, neglect, mistreatment, and exploitation and were found to have been in compliance. CHRC records were also reviewed and found to have been in compliance with no concerning findings identified. 2. CNA #1 did not intervene to protect Resident #1 when they witnessed the alleged incident of sexual abuse by RA #1 by pulling the emergency alarm connected to the call bell, shouting or using a phone to call for help. CNA #1 reported that they were panic stricken and unable to call out for help, but had trouble speaking coherently. CNA #1 stated that they knew they should have stayed with the resident and they should have put the call light on. 3. CNA #1 failed to stay with the resident during the alleged incident of sexual abuse and ensure the residents safety from further sexual abuse. 4. The alleged perpetrator, RA #1, was not immediately redirected to a non-resident care area and supervised after the alleged incident and staff were unaware of the whereabouts of RA #1 thereby allowing him to have access to other residents, specifically, Resident # 2. 5. Staff responding to the room to check on the wellbeing of Resident #1 failed to stay with the resident after they were notified of the alleged incident to ensure her continuing safety. 6. LPN #1 reported that in-service training did not effectively cover how to respond to an active incident of actual or threatened sexual abuse. 7. The security guard had been informed by the ADNS and DNS not to allow anyone to enter or leave the facility, however the security guard did not follow through with the directive. 8. The record of reports made to local law enforcement and the NYS Department of Health were reviewed and determined to be in compliance. 9. The facility established that policy and procedures on specifically preventing sexual abuse needed to be reviewed. 10. The facility established that staff needed to be educated on how to protect residents when an incident of actual or threatened sexual abuse has been identified. 11. The facility established that a system to ensure that staff are adequately supervised while providing care and services to residents must be implemented. B. Identify the specific steps/interventions undertaken or proposed to eliminate and correct the causative factors identified during the assessment phase. 1. The facility implemented corrective action by immediately terminating RA #1, effective 10/30/ 22. 2. The facility promptly notified local law enforcement and cooperated with law enforcement investigation. 3. The facility promptly notified the Department of Health (NYSDOH) by completing the electronic Notification of Occurrence via HCS on 10/30/ 22. 4. The facility retained the services of RN Consultant on 10/30/22, to assist with a Directed Plan of Correction and education. 5. Secure door codes were changed on 10/31/ 22. Resident #1: 1. Resident #1 was immediately transferred to the hospital emergency department for a sexual assault evaluation on 10/30/22 and returned to the facility on ,[DATE]/ 22. 2. Resident #1 returned from the hospital and received social worker supportive visits for emotional support and for monitoring for late signs of psychosocial distress. Supportive visits by social work will remain ongoing, daily, minimally x 90 days. 3. Resident #1 was evaluated by the facility psychologist on 11/1/ 22. 4. Resident #1 was evaluated by the facility psychiatrist on 11/3/ 22. 5. The room of Resident #1 was moved closer to the nurses station on 11/1/ 22. 6. Resident # 1 was care planned for no male care on 11/1/22 and CNA accountability instructions were updated to reflect the same. 7. Victimization and trauma informed care, care plans were updated on 11/1/ 22. 8. Resident #1 has been monitored since 10/30/22 for any behavioral changes or residual effects relating to the alleged incident on 10/30/ 22. Monitoring remains ongoing, minimally x 90 days. Resident #2: 1. Resident #2 was evaluated by RNS on 11/1/ 22. Resident #2 presents with intact cognition and decision making ability and denied that she had been abused, mistreated, neglected or exploited. Resident #2 remains at her baseline. 2. Per RNS, Resident #2 declined physician, psychiatric and psychological supportive assessment as she denied victimization. 3. Social worker supportive visits for emotional support and for monitoring for late signs of psychosocial distress are being provided weekly, minimally x 90 days. 4. At risk for victimization care plan was updated by social work. 5. Resident #2 has been monitored since 11/01/22 for any behavioral changes or residual effects relating to her encounter with RA #1 following the alleged incident on 10/30/ 22. Monitoring remains ongoing, minimally x 90 days. RN Supervisor #1: 1. RNS #1 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. LPN #1: 1. LPN #1 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. CNA #1: 1. CNA #1 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. 2. CNA #1 was offered psychological services on 10/31/22 secondary to witnessing a traumatic event and for support with coping mechanisms to effectively manage stressful situations and emotions. CNA #2: 1. CNA #2 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. CNA #3: 1. CNA #3 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. Security Guard #1 1. Security Guard #1 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. The 1:1 education also addressed the importance of following through with directives. RA #1: 1. RA #1 was immediately terminated on 10/30/ 22. 2. The police investigation of the alleged incident on 10/30/22 remains ongoing. The detective assigned to the case clarified that RA #1 has not been arrested or char |