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Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: March 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY 994 and NY 939) the facility did not ensure that resident's received adequate supervision to remain free from sexual abuse for three (3) of three (3) residents (Resident #2, #3, and #4) reviewed for abuse. Specifically, on 12/16/2024 at approximately 8:00 AM, License Practical Nurse #2 responded to a call for help from the dining room and observed that Resident #1 was touching the genital area of Resident # 2. License Practical Nurse #2 intervened and removed Resident # 2. Resident #1 was left unsupervised and immediately began rubbing the genital area of Resident # 3. Additionally, on 02/22/2025, Registered Nurse #4 heard Resident #4 yelling get out, and when they entered Resident #4's room they observed Resident #4 in bed, the bed linens were pulled down, Resident #4's pants were pulled down below the waist, and Resident #1's hands were at the genital area of Resident # 4. This resulted in actual harm for Resident #2, #3, and #4 which was Immediate Jeopardy with the likelihood to cause harm to the health and safety of other residents. This was evidenced by the following: The review of the facility policy Abuse, Prevention, Identification, Investigation and Reporting dated 06/2023 documented it is the policy of the facility to assure all residents are free from abuse and the facility has taken steps within its control to prohibit and prevent abuse per state, facility and federal regulations. The policy further documented sexual abuse is defined as nonconsensual sexual contact of any type with a resident. Examples of sexual abuse include but are not limited to unwanted intimate touching of any kind especially of the breasts or perineal area. Resident #1 was admitted with [DIAGNOSES REDACTED]. The review of the Quarterly Minimum Data Set (an assessment tool) dated 10/10/2024 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognitive deficit. The review of the Comprehensive Care Plan titled Abuse dated 11/17/2024 documented Resident #1 displays the following behaviors: verbally inappropriate behavior, sexually inappropriate behavior. A care plan update dated 12/16/2024 further documented Resident #1 inappropriately touched peers on 12/16/ 2024. The interventions included every 30-minute monitoring and redirect behaviors. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe impairment for decision making. The review of the Comprehensive Care Plan (CCP) dated 04/24/2024 titled at risk of abuse-victim documented interventions including, monitor for signs of abuse and Psychiatry follow-up as needed. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairments. The review of the Facility Investigation dated 12/16/2024 documented Resident #1 was seated at a table in the dining room waiting for breakfast, and Resident #3 and Resident #2 were seated next to Resident #1 at the same table. Licensed Practical Nurse #2 heard Resident #2 calling for help. Licensed Practical Nurse #2 then observed Resident #1 rubbing Resident #2's clothing at the perineal area. License Practical Nurse #2 immediately removed Resident #2 away from Resident # 1. Resident #1 then proceeded to place their hand inside of Resident #3's pants. Licensed Practical Nurse #3 observed Resident #1 rubbing their own genital area while their other hand was touching Resident #3's genital area. The facility investigation concluded there is probable evidence of abuse, neglect or mistreatment. During an interview conducted on 02/08/2025 at 10:40 AM with Licensed Practical Nurse #2, they stated they were on duty 12/16/2024 and heard Resident #2 screaming. When they responded to the dining room, they saw Resident #1 rubbing Resident #2's clothing at the genital area. License Practical Nurse #2 stated they immediately removed Resident #2 from Resident #1 to separate them. They stated Resident #1 was seated in a chair at the dining/dayroom table and they turned and observed Resident #1 had one hand in their own pants and had their other hand in the pants of Resident #3, and both hands were observed moving up and down. They stated they should have moved Resident #1 away from all other residents. During a telephone interview conducted on 02/07/2025 at 8:30 AM with Licensed Practical Nurse #3, they stated on 12/16/2025 at about 7:45 AM they heard staff and a resident speaking in a loud voice saying stop. Licensed Practical Nurse #3 stated they observed Resident #1 sitting in their wheelchair with their hand inside the pants of Resident # 3. They further stated they unlocked Resident #1's wheelchair and started to move it and then observed Resident #1's other hand inside their own pants touching themselves and both hands were moving in an up and down motion. They stated the dining room is clearly visible when staff are at the nurse's station. When residents are present in the dining room and a nurse leaves the nurses station, the staff periodically check the dining room. They stated they are not aware of any requirement that staff members should be present in the dining room when residents are in that room. During an interview conducted on 02/09/2025 at 3:30 PM with the Director of Nursing, they stated on 12/16/2024 Resident #1, as the aggressor, should have been removed from the day room by Licensed Practical Nurse #2, but they removed the victim. Resident #1 then touched another Resident. They further stated Resident #1 was immediately placed under supervision, one to one (1:1) and transferred to the hospital for aggressive behavior. The Director of Nursing stated Resident #1 was seen in the emergency department and returned without further recommendations. The Director of Nursing further stated Resident #1 was scheduled for psych follow-up outpatient but was not able to locate the consult forms. Resident #4 had a [DIAGNOSES REDACTED]. Review of the Facility investigation dated 02/22/2025 documented Resident #1 was observed in Resident #4's room. An employee statement obtained by Registered Nurse #2 documented Registered Nurse #4 stated they saw Resident #1 in the room of Resident #4 touching and rubbing the genital area of Resident # 4. The facility investigation concluded there is probable evidence of abuse, neglect or mistreatment. During an interview conducted on 03/04/2025 with Certified Nursing Assistant #4 they stated on 2/22/2025, during the 3:00 PM to 11:00 PM shift, they observed Resident #1 hanging around Resident # 4. They stated before they went on break, they told Registered Nurse #1 to watch Resident #1. When they returned from break Registered Nurse #1 informed them that Resident #1 was observed rubbing the genital area of Resident #4 and attempted to touch Registered #4 inappropriately. During an interview conducted with Registered Nurse #4 on 03/04/2025 at 12:20 PM, they stated on 02/22/2025 at approximately 10:00 PM they responded to the room because Resident #4 was yelling get out, and they observed Resident #1 at the bedside. The sheet and pants of Resident #4 were pulled down and Resident #1's hands were observed extended over Resident # 4. During an interview conducted with Registered Nurse #2 on 03/04/2025 at 11:34 AM they stated prior to 02/22/2025 Resident #1 was on 30-minute checks. They further stated Resident #1 was moved to the current unit secondary to sexual | Plan of Correction: ApprovedMarch 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-600 I. The following actions were accomplished for the residents identified in the sample: Resident #1 Resident #1 was hosptalized on [DATE] and remains in the hospital. If the resident is discharged back to the facility, the IDCPT will develop a care plan that addresses the residents risk of abusing other residents and to be abused with resident-specific care plan interventions. The facility has determined that the resident may require one-to-one supervision when he returns to the facility, but a determination will be made on his return. Resident #2 The resident was seen by the social worker on 12/16/2024 and had no recollection of the incident from earlier in the day. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 12/24/2024 following the resident-to-resident sexual abuse incident and no complaints were identified. The resident continues to be free of any psychological symptoms of distress. The IDCP Team updated the plan of care on 12/16/2024 to address the residents risk to be abused. On 3/26/2025 the IDCP Team completed an additional review of the residents risk to be abused care plan and updated it to include person centered interventions based on the residents involvement with family and interest in recreational activities including -- - Provide the resident with a cup of coffee and home magazines to flip through - Weekly rosary program - Utilize catholic prayers (Hail (NAME) and Our Father to calm the resident) - Music programs with emphasis on show tunes (favorite music) - Resident was removed from the early get up list, by preference (hx of combative behavior during caregiving ) The resident has not been involved in any negative peer to peer interaction since 12/16/ 24. Resident #3 The resident was seen by the social worker on 12/16/2024 and had no recollection of the incident from earlier in the day. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 12/17/2024 following the resident-to-resident sexual abuse incident and no issues were identified. The resident continues to be free of any psychological symptoms of distress. The IDCP Team updated the plan of care on 12/16/2024 to address the residents risk to be abused. On 03/26/2025 the IDCP Team completed an additional review of the residents potential for abuse care plan and added additional person-centered interventions including -- - provide opportunities to watch old movies with her peers - play music of preference i.e. Sinatra, Dean Martin, Perry Como - participation in Busy Bees table to engage in diversional activity- ensure game is provided to the resident first, as per preference and history of grabbing items from others The resident has not been involved in any negative peer to peer interactions since 12/16/ 25. Resident #4 The resident was seen by the social worker on 2/24/2025 and had no recollection of the incident that occurred on 2/22/ 2025. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 02/24/2025 following the resident-to-resident sexual abuse incident and no distress was identified at that time. The resident had been followed by psychiatry and psychology since readmission on 5/14/2024 related to her behaviors/ [DIAGNOSES REDACTED]. depression. She continues to be followed by both services and is closely monitored related to ongoing behaviors i.e. refusals of care, wandering, flirtatiousness comments, verbal outbursts. The resident is currently on 30- minute checks related to her behaviors. [MEDICAL CONDITION] medications inclusive of [MEDICATION NAME] sprinkles, duloxetine, [MEDICATION NAME] and trazadone continue to be part of the residents treatment plan. The IDCP Team updated the plan of care on 02/24/2024 to address the residents risk of being abused. On 03/26/2025 the IDCP Team completed an additional review of the residents risk of being abused. The care plan was updated to include -- - if resident is upset and/or agitated call nephew or cousin to allow resident to speak with them - offer activities of specific resident interest i.e. Good Housekeeping magazines, cards, casino games - Utilize soda and sweet snacks to divert from undesirable comments/behaviors (resident preference) - if resident refuses care, provide time and space and reapproach The resident has not been involved in any negative peer to peer interactions since 02/22/ 2025. On 03/05/2025, the facility developed and implemented a plan for Abuse Prevention education related to the immediate jeopardy situation to ensure all staff received this education prior to the start of their next assigned shift. 89% of staff on duty completed the education by 03/07/ 2025. This education continued through 03/25/ 2025. 100% compliance was met by all departments, other than nursing, which has a compliance rate of 96%. Directed In-service is scheduled to be initiated on 04/01/ 2025. II. The facility was notified of the immediate jeopardy situation on 03/05/2025 and implemented the following: The facility convened a QAPI meeting on 03/06/2025 to discuss the root cause of the abuse situation Administration initiated staff training on the following topics on 03/06/2025 -- o Reporting process o How to report Abuse, Neglect and Mistreatment o Unit Behavior Management meeting o 1:1 observation and 30-minute monitoring o Role of the RN Supervisor regarding reporting abuse, neglect and mistreatment o Safeguarding residents with cognitive impairments against sexual and/ or inappropriate behaviors II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Please refer to corrective actions outlined at Sections II, III and IV of this DP(NAME). The CNO reviewed all Incident Reports for the period of 01/ 5 to 03/25/2025 and no additional events of abuse have occurred. The DNS/designee will continue to review all new Incident Reports daily to ensure prompt follow-up is completed for any type of abuse report. The facilitys QAPI Committee and outside consultant participated in a DP(NAME) QAPI meeting on 03/25/2025, to discuss the issues identified at F-600 and conducted a Root Cause Analysis. During this meeting, the outside consultant provided education to the Committee members on Abuse Prevention principles and how non-adherence to abuse prevention practices, including management of resident sexual behaviors, can result in deficient practices such as those cited in the SOD. Education also addresses use of a Root Cause Analysis when compliance issues are identified All resident care plans related to abuse risk, at risk to be a victim or to victimize, requiring behavior management or other interventions to prevent are being reviewed by the IDCPT and updated, as necessary, to address the residents current needs and problems and to ensure preventative measures are in place. If a care plan indicating potential risk to be a victim or to victimize has not been developed, one will be initiated, for all identified at risk residents. Nurse Managers will review the plan of care with the unit staff responsible and update the care plan and Kiosk as indicated. Effective 04/01/2025 through 04/03/2025, education will be provided by the outside consultant to all facility staff on the facilitys Abuse Prohibition protocols including behavior management principles for residents at risk to abuse and those at risk of being abused. The education will include types of abuse; need for identification and monitoring of resident behaviors that may result in a potential abuse situation for another resident and staff response to behavioral symptoms with appropriate interventions to prevent abuse from reoccurring. This education will continue to be provided until all facility staff receive |