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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 31, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Abbreviated survey completed on 12/31/24 (Complaint # NY 248) the facility did not protect residents from sexual abuse for two (Resident #1 and #2) of three residents reviewed for abuse. Specifically, Resident #1 wandered into Resident #2's room without staff knowledge and they were found engaged in sexual activity. Resident #1 and Resident #2 both lacked the ability to consent due to their cognitive impairment. The finding is: The policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised (MONTH) 2021, documented residents have the right to be free from abuse by anyone which includes but is not limited to verbal, mental, sexual, and physical abuse. Establish and maintain a culture of [MEDICATION NAME] and caring for all residents and particularly those with behavior, cognitive and emotional problems. The policy titled Identifying Sexual Abuse and Capacity to Consent, dated (MONTH) 2022, documented a resident's consent to sexual activity is not valid if obtained from a resident who lacks capacity to consent, or if consent was obtained through intimidation, fear, or coercion. Sexual abuse is non-consensual sexual contact of any type with a resident, including unwanted intimate touching of any kind especially of breasts or perineal area. Sexual contact is non-consensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is sexual abuse. For any allegations or suspicion of sexual abuse, an investigation, protective measures will be implemented to prevent further potential abuse. 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 9/26/24 documented the resident was cognitively intact and independent with ambulation and transfers. Resident #1's comprehensive care plan documented the following: -11/13/24 they were at risk for mood and behavior problems related to medical decline and diagnoses. -11/18/24 they had impaired cognitive function and dementia. The progress note dated 10/15/24, written by Nurse Practitioner #1, documented Resident #1 had past medical history significant for anxiety, depression, and questionable dementia. The resident was seen for an acute visit per current director of nursing and administrator request. Staff found patient having a sexual encounter with another patient on the unit. A Brief Interview for Mental Status (BIMS) assessment dated [DATE], conducted by the Director of Quality Assurance #1, documented Resident #1 scored a 3, indicating they were severely cognitively impaired. 2. Resident #2 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident was severely cognitively impaired, was understood and understands. Resident #2's comprehensive care plan documented the following: -10/15/24 they had an episode of intimate contact with a peer. -11/29/24 they had behavior problems related to often removed clothing, not always redirectable and had [MEDICAL CONDITION]. An unsigned Brief Interview for Mental Status (BIMS) assessment dated [DATE], documented Resident #2 scored a 5, indicating they were severely cognitively impaired. A Progress Note dated 10/14/24 at 10:03 PM, written by Licensed Practical Nurse #1, documented Resident #2 was having sexual intercourse with another resident. The Witness Statements written by a Certified Nurse Aide dated 10/14/24, documented the door to the room was closed, they knocked, entered, and saw Resident #2 on top of Resident #1 having sexual intercourse. The Certified Nurse Aide told them to stop and the residents jumped. The Certified Nurse Aide went and told the nurse (Licensed Practical Nurse #1) what they witnessed. The progress note dated 10/15/24, written by Nurse Practitioner #1, documented Resident #2 had past medical history significant for [MEDICAL CONDITION], type 2 diabetes, and [MEDICAL CONDITION]. The resident was seen for an acute visit per the director of nursing and administrator request. Staff found this patient and another patient having sexual relations, they were immediately separated by staff. The resident was assessed for injuries, none were found. An Investigation Summary/QA Privilege report signed on 10/17/24 by the Interim Director of Nursing #1 documented Resident #1 and Resident #2 were alert, pleasant and cooperative with staff and peers. Both had impaired cognition, and no mood or behavior problems. On the date of the occurrence (10/14/24), Resident #1 was found in the room of Resident #2 in a compromising sexual encounter position. Both residents lacked insight and judgement. During an observation and interview on 12/13/24 at 12:16 PM, Resident #2 was observed sitting on the side of the bed with only a sheet covering their front and back private areas. The resident was able to answer simple yes/no questions regarding their day and did not recall any incidents with any other residents. During an interview on 12/13/24 at 12:51 PM, the Interim Director of Nursing #1, with the Director of Quality Assurance #1 present, stated they believed both residents did not have capacity, Resident #1's cognition fluctuated. The investigation concluded it was consensual between both residents, both residents had no psychological harm from the incident, and it was reported to law enforcement. The facility never heard back from authorities. Resident #2 was moved to a room on a different floor. The Director of Quality Assurance #1 stated Resident #1 thought Resident #2 was their spouse. During a telephone interview on 12/18/24 at 11:00 AM, Licensed Practical Nurse #1 stated they were at the nurse's station at the medication cart and heard an aide yelling for them to come to Resident #2's room. When they entered the room, they observed Resident #1 lying on the bed with their brief down near their feet and their legs open and Resident #2 standing at the side of the bed with their pants and brief down leaning over Resident # 1. Licensed Practical Nurse #1 asked both residents what was going on and immediately separated the two residents. Both residents seemed startled when staff entered the room. Resident #1 stated to Licensed Practical Nurse #1, that Resident #2 tried to seduce them. They did not see any actual sexual activity between the two residents. They also stated that just prior to the incident, Resident #1 was redirected to their room. The supervisor was called, and the police came. Resident #1 was put on 1:1 supervision. At the time neither resident seemed upset nor crying. Resident #1 would wander the unit and at times made inappropriate sexual comments or gestures. During a telephone interview on 12/18/24 at 11:28 AM, Licensed Practical Nursing Supervisor #1 stated they were not on the floor at the time of the incident. Staff reported the incident to them. They believed they completed the accident and incident report and obtained resident and staff statements. Resident #1 would wander and would have to be redirected. Resident #1 also had a history of [REDACTED]. Licensed Practical Nursing Supervisor #1 stated they did not know any of Resident #2's medical background or if Resident #2 had capacity and was unsure if Resident #1 had capacity, but the resident can be confused. During a telephone interview on 12/18/24 at 11:40 AM, Resident #2's Responsible Party stated the facility informed them of the incident that happened between Resident #1 and Resident # 2. The facility told them there was some kind of sexual contact between the two residents. Resident #1 may have touched Resident #2's private area but not much information was given to them. Resident #2's Responsible Party stated they went to the facility and talked to Resident #2 and asked them what happ | Plan of Correction: ApprovedJanuary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #1 was discharged on [DATE] and has since passed away a. Resident #2 had a room/floor change after incident occurred. Resident #2's care plan has been reviewed and found to be appropriate. a psychosocial evaluation has been completed by social work and resident doe snot even re- call the incident. b. No further incidents have occurred. II. All wandering residents who lack capacity have the potential to be affected by this deficiency. a. A 100% audit of current residents who lack capacity, that may be displaying behaviors (handholding, arms around each other, seating preferences etc.) will be conducted. Any concerns will be brought to the IDT and the behaviors and potential relationship will be reviewed and interventions will be care planned as appropriate. III. Facility policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised (MONTH) 2021 and Identifying Sexual Abuse and Capacity to Consent, dated (MONTH) 2022 have been reviewed, and found to be appropriate. a. A monthly ?ôrelationship meeting?Ø will be held to include Administrator, DON, Social Work and the Dementia Unit Manager/Designee to discuss/identify any residents that may be displaying behaviors that could suggest a developing relationship between residents. The Unit Manager/Designee will be the chairperson/spokesperson for all nursing employees assigned to the unit. Care plans and further interventions updated as indicated. b. All nursing staff will be educated on the establishment of the 4th floor ?ôrelationship meeting?Ø. c. All nursing staff will be educated on identification and reporting any residents who are displaying behaviors such as (hand holding, arms around each other, seating preference, etc.). d. Any staff reports related to the identification of the potential for resident relationship development will be reported immediately to their immediate supervisor. Nursing Supervisory staff will be educated to begin the process of convening the IDT to audit the circumstance of this relationship to include resident capacity, family and MD notification and care plan review. IV. Any changes in behavior or adverse interactions will be reported immediately to DON/Administrator or designee and brought to morning report daily for review and QAPI monthly. a. Administrator will audit the monthly relationship meetings to ensure completion and follow through monthly x 3 months, then quarterly thereafter. b. At monthly QAPI the Administrator will review the results of the monthly relationship meeting and any other reported occurrences of potential relationships developing. V. The administrator is responsible for this plan. |