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Scope: Isolated
Severity: Actual harm has occurred
Citation date: January 23, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the abbreviated survey (NY 636), the facility failed to protect the resident's right to be free from sexual abuse for one (1) of five (5) residents (Resident #5) reviewed. Specifically, Resident #5, who was not competent to give consent, was sexually assaulted by Resident #4. The facility's failure to protect residents from sexual abuse resulted in harm past non-compliance, that was not Immediate Jeopardy for Resident #5. Findings include: The facility policy Prevention of Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property revised 1/20/2023, documented residents in the facility were to be free from abuse neglect and exploitation. All staff are in-serviced annually and upon hiring on prevention of abuse, neglect, involuntary seclusion, and misappropriation of property and will report abuse immediately. Abuse is a willful act of verbal abuse, sexual abuse, nonconsensual sex contact of any type, physical abuse, and mental abuse. Resident #4 had [DIAGNOSES REDACTED]. The 8/7/2024 Brief Interview for Mental Status (an assessment tool) score was 13/15 indicating the resident's cognition was intact and they were able to make their own decisions and needs known. Resident #5 had [DIAGNOSES REDACTED]. The 8/9/2024 Brief Interview for Mental Status score was 0/15 indicating the resident had severe cognitive impairment. The 8/07/2024 and 8/08/2024 nursing progress notes documented the resident was alert, confused, nonverbal, and staff were to anticipate their needs. They had a gastrostomy tube (tube inserted into the stomach to receive liquid nutrition) in place and received tube feedings and medications via this tube. The resident was ambulating around the unit. Resident #5's comprehensive care plan, initiated 8/7/2024 documented the resident had potential for wandering and potential to be a victim of abuse. Interventions included: intervene when the resident was wandering into other rooms; monitor the resident's whereabouts and redirect; observe for anxiety; wander alert device to their right ankle; and monitor socialization. The 8/16/2024 nursing progress note by Licensed Practical Nurse #17 documented Resident #5 entered other residents' rooms and took food from meal trays. The 8/17/2024 nursing progress note by Registered Nurse Supervisor #9 documented they were notified Resident #5 was in another resident's room, undressed with their brief on the floor, and sitting on the side of the bed. The resident was removed from the room and was assessed. The resident was guarded, they had no pain, their inner upper thighs were red, labia was red, and they were incontinent of urine. The physician was notified and ordered to send the resident to the emergency department for evaluation. The 8/17/2024 Incident and Accident Report completed by Registered Nurse Supervisor #9 documented: - on 08/17/2024, Resident #5 was last observed walking in the hallway between 2:50 PM to 2:52 PM by assigned Certified Nursing Assistant #12. - At approximately 3:30 PM, Certified Nurse Assistant #10 reported to Registered Nurse Supervisor #9, Resident #5 and Resident #4 were in Resident #4's room and both residents were naked, and Resident #4 was lying over Resident #5 with their clothes on the floor and the feeding tube was no longer connected to Resident #5's abdomen. - Resident #5 was removed from the room and brought to their room where a gown was placed on them, and a certified nursing assistant stayed with Resident #5 until the ambulance arrived. - Registered Nurse Supervisor #9's statement documented when they went to the unit, Resident #4 was lying in bed, there was tube feeding liquid on the floor next to the bed and on the sheets located on the bed, and there was urine on the floor. When Resident #4 was asked what happened they verbalized that they were attempting to have sexual intercourse with Resident #5. They answered questions appropriately. The resident was placed on 1:1 supervision, where a staff person stayed with them until they were discharged and taken into police custody. - The nursing assessment completed by Registered Nurse Supervisor #9 found Resident #5 had redness to inner thighs and labia and was incontinent of bladder and bowel. There was fluid present which appeared to be tube feeding fluid that was leaking from their abdomen. The resident was agitated and visibly upset at the time of the exam. - The Administrator was notified at 3:45 PM, the physician and families were notified at approximately 4:10 PM. - The police were notified, and emergency services summoned for transport to the hospital. - Resident #4 was placed under arrest and discharged to the Sheriff's department at 7:30 PM. - Staff from all shifts were interviewed and there were no previously reported incidents Resident #4 made sexual remarks or attempted any inappropriate physical contact with staff or residents. There were no witnesses to Resident #5 entering Resident #4's room prior to the event. The 8/17/2024 at 6:15 PM hospital emergency department report documented Resident #5 presented with alleged sexual assault. The resident was significantly limited verbally and developmentally delayed. -It was reported that staff walked in on another resident attempting to sexually assault/rape this resident. This resident was unable to consent. -Evaluation showed the resident was alert and able to move all extremities and had no signs of acute distress. Vital signs were within normal limits. The resident had a small abrasion to central forehead. There were no signs of obvious significant injury, deformity, or trauma to their vulva or groin. Mental status was at baseline. -The resident's feeding tube was dislodged during assault and replaced. -The resident had a comprehensive sexual assault examination by a registered nurse with photos and specimens obtained. There was no discharge or bleeding noted from the vaginal area. The resident grimaced during the exam. This resident had entered the accused resident's room and was found with no clothing and the accused resident reported we had sex. -The resident was stable and appeared to have been sexually assaulted by another resident. Concerned that resident may have had a [MEDICAL CONDITION] during this event. Findings were noted as sexual assault, breakthrough [MEDICAL CONDITION] and dislodged gastrostomy tube. During an interview on 12/16/2024 at 3:22 PM, Licensed Practical Nurse #15 stated on 8/17/2024, Certified Nurse Aide #10 reported they had removed Resident #5 out of Resident #4's bed and put them in their own bed. Licensed Practical Nurse #15, Certified Nurse Aide #9, and Licensed Practical Nurse #14 went to Resident #4's room. Resident #4's pants were partially down. Resident #5's brief was on the floor and there was tube-feeding formula all over. They went back to Resident #5's room; the resident looked sad and was making sounds and different voices. They assisted the resident by trying to clean them up and put clothes on them. Licensed Practical Nurse #14 called Registered Nurse Supervisor #9 who took statements from all staff on the unit. The police were in Resident #4's room for a long time. Resident was on 1:1 observation until the police arrived and left with the police. During an interview on 12/16/2024 at 3:40 PM, Licensed Practical Nurse #14 stated on 8/17/2024 Certified Nurse Aide #10 reported to them Resident #4 was in their room unclothed, on top of Resident #5 who was also unclothed. When the licensed practical nurse arrived at Resident #4's room, the resident was dressed. They then went to Resident #5's room and saw they were covered and in bed. The resident's gastrostomy tube was out, and they notified Registered Nurse Supervisor #11. During a phone interview on 12/17/2024 at 2:36 PM, Registered Nurse Supervisor #9 stated on 8/17/2024, they were notified by certified nurse aides (unnamed) they needed help on the unit. The unit staff had already separated the two residents and stayed with them. The assessment was completed, the physician and Administrator were notified, and an ambulance was called to send Resident #5 to the hospital for evaluation. The Sheriff and a detective arrived and took Resident #4 away. Resident #4 was newer to the facility and had been there about a week prior to the incident. During an interview on 1/13/2025 it 12:35 AM at 1:30 PM, Certified Nurse Aide #12 stated on 8/17/2024 they were assigned to care for Residents #4 and #5, and that was the first time they had cared for either resident. Resident #4 did not come out of their room the entire shift. They saw them several times during the shift in their room when they checked on them and provided care. Resident #5 was at therapy in the morning and when they returned, was observed wandering the unit. Certified Nurse Aide #12 provided care to the resident around 1:50 PM, covered the resident in bed, and turned off their lights. They were directed to go on break from 2:15-2:45 PM. When they returned, they did final rounds on residents and observed Resident #5 wandering the hall. They left the facility for the day around 2:52 PM. During a telephone interview on 1/21/2025 at 11:35 AM, Certified Nurse Aide #10 stated they typically visualized their residents at the beginning and end of their shifts, and throughout the shift as they responded to call lights, checking rooms as they did their rounds. On 8/17/2024, they started their safety rounds and picking up lunch trays left by the previous shift around 3:15 PM. They went to Resident #5's room and the resident was not there. They went to the next room, which was Resident #4's room, knocked on the closed door, and went directly to the second bed by the window to see if there was a tray left in the room. Certified Nurse Aide #10 saw Residents #4 and 5 fully undressed on Resident #4's bed. They immediately took Resident #5 back to their room and called for help. During a phone interview on 1/22/2025 at 10:49 AM the Director of Nursing stated Resident #5 was assessed upon admission for behavioral needs and monitoring, they did not require continuous monitoring for their wandering. All nursing staff were educated on abuse and wandering following the incident. No policy or procedure changes were made. Education was for review, due to the incident. No care plan violations or delays in reporting were identified. The facility Quality Assurance and Performance Improvement meeting was held on the third Thursday of every month and this incident was reviewed and abuse is an ongoing area of review. 10NYCRR 415.4(b)(1)(i) ______________________________________________________________________________ Deficient practice was identified in the area of sexual abuse that resulted in harm to Resident #5 by Resident #4. The facility provided verification the following corrective actions were completed by 8/24/2024: - On 8/17/2024, female residents who reside in the facility on the same unit as Resident #4 were interviewed by the Director of Operations to determine if there was any interaction with Resident #4 prior to this incident and if they felt safe at the facility. There were no female residents who identified they felt unsafe nor had any contact with the resident. There was ongoing evaluation of female residents on the unit for any change in behavior. - The staff on the unit were reinterviewed to determine if Resident #4 demonstrated any behaviors that indicated the potential for abuse by Resident #4 and none were identified. - From 8/17/2024 through 8/24/2025, all staff were educated on abuse, the necessity for prompt action, including securing evidence and to reinforce policies and procedures in response to incidents of actual or suspected sexual abuse and reporting. Additional education included wandering prevention and managing cognitively impaired residents. - This incident was reviewed at the Quality Assurance and Performance Improvement meeting in 8/2024. Abuse and incident reviews continue at monthly Quality Assurance meetings. -Neither resident returned to the facility. | Plan of Correction: ApprovedFebruary 19, 2025 A plan of correction is not required for past non-compliance deficiencies. The facility has implemented corrective actions to ensure ongoing compliance. |