Pontiac Nursing Home
October 19, 2020 Complaint Survey

Standard Health Citations

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 19, 2020
Corrected date: December 1, 2020

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview during the abbreviated survey (NY 348, NY 801 and NY 670), the facility did not ensure residents had the right to be free from abuse for 4 of 4 residents reviewed (Residents #1, 2, 3, and 4). Specifically, - Resident #2 was admitted with known sexual predator status and the facility did not develop and implement a plan to prevent sexual abuse. - Resident #2 sexually abused Residents #1, 3, and 4, who could not consent to sexual contact. This resulted in actual harm to Resident #1 and no actual harm with potential for more than minimal harm to Residents #3 and 4. Findings include: The 3/21/2019 facility Abuse policy documented all residents will be protected from abuse, neglect, mistreatment, sexual coercion, or assault. Resident #2 had [DIAGNOSES REDACTED]. The 5/1/2019 MDS assessment documented the resident had no short or long-term memory impairment and was independent with decision making. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The 8/4/2020 MDS documented the resident's cognition was severely impaired. Resident #3 had [DIAGNOSES REDACTED]. Resident #4 had [DIAGNOSES REDACTED]. INCIDENT #1 Resident #2's discharge instructions from the skilled nursing facility the resident was admitted from dated 5/24/2019, documented the resident was discharged because his needs could not be met. The resident was at high risk for heterosexual behavior and exposed his penis to others. Resident #2's comprehensive care plan (CCP) dated 5/24/2019 documented the resident had potential to abuse others. Interventions included to monitor frequently, update medical providers with any changes, and provide 1:1 activity. The incident/accident report and investigation dated 5/25/2019 at 5:00 PM, documented Resident #3 was found in Resident #2's room. Resident #3 was sitting in her wheelchair and Resident #2 was standing up in front of Resident #3. Resident #2 was holding Resident #3's hands and Resident #2 was sexually aroused. The facility reviewed the camera footage and observed Resident #2 wheel Resident #3 in the wheelchair into Resident #2's room. The residents were separated, and 15-minute checks were implemented. Later on, during the shift, staff again found Resident #2 sitting knee to knee with Resident #3. Both Residents #2 and 3 resided on Unit #2 at the time of the incident. Resident #2's CCP documented: - On 5/26/2019, the resident was attempting to get close to Resident #3. - On 5/27/2019, the resident made contact with an unidentified resident and 15-minute checks were initiated. This information was conflicting as the resident was placed on 15-minute checks on 5/25/2019 per the incident report and there was no documentation they were discontinued. The 5/29/2019 Administrator's progress note, included with the 5/25/2019 incident report, documented after admission, she became aware the resident was a known sexual predator from another state and on 5/25/2019, the resident took a non-consenting female into his room. Resident #2 was being sent out for an evaluation due to seeking out Resident #3. On 5/29/2019, the resident was returned to the facility and moved to Unit #1. There were no corresponding records from the hospital or psychiatric evaluation. The facility was unable to provide documentation the 15-minute checks were completed consistently after Resident #2 returned from the hospital or when they were discontinued. INCIDENT #2 The social services progress notes on 8/20/2019 documented the social worker asked Resident #2 to move to Unit #2 to accommodate a resident moving to Unit #1. The resident agreed and Resident #2 moved to Unit #2 on 8/23/2019. The 10/19/2019 investigation summary documented Resident #4 was observed by a certified nurse aide (CNA) holding Resident #2's penis while sitting in the day room. The residents were immediately separated after the incident and 1:1 supervision was initiated for Resident #2. Upon review of the camera footage, the facility determined prior to the incident, Resident #2 walked by the day room and showed his penis to Resident #4. Resident #2's medical record contained no documentation when 1:1 monitoring was discontinued. When requested, the facility was unable to provide documentation as to how Resident #2 was monitored to prevent further incidents from (MONTH) 2019 through (MONTH) 2020. Resident #2 remained on Unit #2 following this incident. INCIDENT #3 The 3/17/2020 facility investigation summary, completed by the Administrator, documented on 3/14/2020 at 12:31 PM Resident #1 was in Resident #2's room. Resident #2's head was on Resident #1's breast while Resident #1 held Resident #2's penis. The residents were immediately separated, the Supervisor was notified, 15-minute checks were initiated, and a stop sign was to be placed on both residents' doors. The social work note dated 3/14/2020 documented she talked with Resident #2 who waved his hand at her and would not speak. She educated the resident on not touching or being touched or allowing residents in his room. Resident #2's CCP was updated 3/16/2020 and documented a resident to resident incident on 3/14/2020 with interventions including staff to be observant of resident's location, redirect the resident, monitor behaviors and report any inappropriate behaviors. The CCP was updated and documented 15-minute checks and a stop sign was applied to the resident's door. The 3/17/2020 interdisciplinary team progress note documented at 11:00 AM Resident #2's 15-minute checks were discontinued, and 30-minute checks were initiated after a discussion with the physician. Staff were to monitor the resident for effect. Resident #2's nursing progress notes documented: - on 3/18/2020, Resident #2 was noted to encourage Resident #1 to wander off with him and Resident #2 was aware of Resident #1's locations on the unit. - On 3/21/2020, Resident #1 went to Resident #2's room and was redirected by staff. - On 3/23/2020, Resident #2 was wandering in the hall and redirected away from Resident #1's room. - On 3/24/2020, Resident #2 continued to wander toward Resident #1's room while Resident #1 was within eyesight. Resident #2 was redirected to his room and 30-minute checks continued. - On 3/25/2020, Resident #2 continued to seek where staff were with attempts to wander toward Resident #1. Resident #2 was redirected several times. - On 3/26/2020, 7:00 AM -3:00 PM 30-minute checks continued. INCIDENT #4 The 3/26/2020 facility incident summary documented at 4:30PM; - Resident #2 was found on Resident #1's bed on Unit 2. Resident #1 was unclothed and Resident #2 had his hand inside Resident #1's vagina. - The plan was for 15-minute checks and Resident #2 was to be moved to Unit 1 and have a motion detector on his door. - CNA #5's statement dated 3/26/2020 and included in the facility investigation, documented she found Resident #1 lying on the bed without clothes on and Resident #2 had his whole fist inside of Resident #1's vagina. She told Resident #2 to stop and made the resident leave the room. She notified a Supervisor. The 4/3/2020 psychiatric behavioral note documented approximately 1-week prior Resident #2 was engaged in sexual behavior. There was heightened concern because per the staff Resident #2 was on the sex offender's registry for a [AGE] year-old charge in another state. Resident #2 was placed on 15-minute checks to 30-minute checks. After that he was again found in the room. The resident was then moved to a floor below. The Director of Social Services was interviewed on 9/10/2020 at 1:18 PM, and stated she was informed of the incident between Residents #1 and 2 on 3/26/2020 at approximately 6:00 PM by LPN #1. She went to Unit 2 and saw Residents #1 and 2 who had been separated and were near the nursing station. She contacted the Administrator and Director of Nursing (DON) and the intervention was to move Resident #2 to Unit 1, place the resident on 30-minute checks, and place a motion sensor on the room door. Resident #2 was moved to Unit 1 on 3/26/2020. She stated Resident #1 had advanced dementia and would not be able to make an informed decision. She talked to Resident #2 the following day, and the resident denied touching Resident #1. She again provided education to Resident #2 not to enter female residents' rooms. Licensed practical nurse (LPN) #1 was interviewed on 9/10/2020 at 2:48 PM and stated she worked on 3/26/2020 on the 7:00 AM to 3:00 PM shift and then on the 3:00 PM to 11:00 PM shift. She stated when she was notified of the incident, she notified the Director of Social Services for further guidance. The residents were separated, and Resident #2 was placed on 15-minute checks and moved to Unit 1. She stated Resident #1 had severe dementia and Resident #2 had mental health issues. CNA #5 was interviewed on 9/11/2020 at 8:50 AM via telephone, and stated she worked on 3/26/2020 from 2:00 PM to 10:00 PM. While doing rounds that night she was not able to locate Resident #2. She went to look for the resident and found Resident #2 lying on top of Resident #1 with his fist, up to the wrist, inserted in Resident #1's vagina. She told Resident #2 to get out of the room and immediately reported the incident to the nurse. Both residents were placed on 15-minute checks. The Director of Nursing (DON) #6 was interviewed via telephone on 9/21/2020 at 9:54 AM, and stated she worked at the facility from (MONTH) 2020 to mid-April 2020. She was notified via telephone of the incident on 3/26/2020. She directed the staff to provide 1:1 for Resident #2 while he remained on the unit and he was to be relocated to another unit. Resident #1 was to be placed on 15-minute checks. Once Resident #2 was moved to Unit 1, he was to be monitored every 15 minutes. INCIDENT#5 On 7/18/2020, Resident #2 was sent to the hospital for an unrelated medical issue. The resident returned to the facility on [DATE] and was readmitted to Unit 2 (the Unit where Resident #1 resided). Resident #2's 15-minute check sheet did not document Resident #2 was consistently monitored from 7/23/2020 -8/23/2020 per the plan of care. The facility incident/accident report dated 8/22/2020 documented at 3:15 PM on Unit 2, Resident #2 was found straddling Resident #1 on his bed. Resident #2 was observed half naked. Resident #1's pull up (adult brief) was just off the hips. Resident #1 stated you caught us just in the nick of time. The residents were separated. The responsible party and physician were notified. Resident #1 was removed from the room and Resident #2 was moved to Unit 1. The 8/22/2020 resident to resident summary of abuse documented at approximately 3:15 PM, CNAs #5 and 7 entered Resident #2's room, the door was closed, and they observed Resident #1 lying on Resident #2's bed with her brief pulled down on her hip. Resident #2 was naked from the waist down and kneeling over Resident #1 with his knees on the bed. The residents were separated and Resident #2 stated he did what he did and reported his hands were there while pointing to her genital area. Resident #2 was moved to Unit 1 and placed on 10-minute checks. CNA #7 stated during a telephone interview on 10/15/2020 at 8:42 AM that on 8/22/2020, her and another CNA (CNA #5) were providing care and answering call bells. Prior to leaving to answer a call bell, Resident #1 was sitting in the hall by the nursing station. When they returned to the nursing station, they were unable to locate Resident #1. They went to look for the resident and went to Resident #2's room. Resident #2 was straddled over Resident #1 on the bed. Resident #2's pants were around his knees and Resident #1's pants were below the vaginal area. She stated, it looked to her as though Resident #2 pulled his penis out of Resident #1's vagina when they entered the room. She stated she thought there was vaginal penetration. She yelled What are you doing? and the other CNA got the nurse. CNA #5 was re-interviewed on 10/15/2020 at 8:42 AM and stated on 8/22/2020 she went to find Resident #1 and was unable to locate the resident, so she and CNA #7 went room to room and located Resident #1 in Resident #2's room. When she entered, she found Resident #2 straddling Resident #1 on the bed. Resident #2's pants were pulled down to his knees and Resident #1's pants were pulled down below her vaginal area. Registered nurse (RN) #10 was interviewed on 10/6/2020 at 1:17 PM and stated she was notified by LPN #9 on 8/22/2020 of the incident between Residents #1 and 2. She was told Resident #2 was positioned over Resident #1 and Resident #1's attends were pulled down below the vaginal area. Resident #2 was straddled over Resident #1. By the time she arrived on the unit, 2-3 minutes, later Resident #1 was in her room and Resident #2 was in his room. When she went to see Resident #1, she observed the resident fully dressed sitting on the bed, confused. She asked her how she was, and the resident stated she was okay and stated, he did what he did. She asked Resident #1 what she meant, and the resident stated his hands were there as she pointed to her private parts. She then when to see Resident #2, she looked at him and did not notice anything in particular. Resident #2 was sitting in a chair with a sheet over him. RN #10 stated, that was that. She completed her note and signed that she assessed the residents. RN #10 stated she did not look at the resident's body parts including Resident #1's vaginal area because she was told nothing happened and the residents were separated. Both residents were on Unit 2 at the time of the incident. She told the DON what happened, and Resident #2 was moved to Unit 1. She did not know what day Resident #2 was moved from Unit 2. DON #7 was interviewed on 10/6/2020 at 2:00 PM, she stated she had been in the position since (MONTH) 2020. She conducted the investigation of the (MONTH) 2020 incident. She did not think 2 cognitively impaired residents could consent to sexual activity. She was not aware Resident #2 was a convicted sexual predator until she investigated the incident on 8/22/2020. She was not present at the time of the incident and was made aware, while at home, from the LPN charge nurse and RN #10. The residents had been separated at that time and she instructed the staff to move Resident #2 off the unit. She directed them to initiate an incident report and continue with 15-minute checks. She did not feel abuse occurred. The Administrator was interviewed on 9/10/2020 at 3:30 PM and stated the social worker was responsible to meet with residents after any resident to resident situation and address the behaviors. The Administrator was interviewed on 10/6/2020 at 2:40 PM and stated she defined abuse, according to the facility policy, as the willful intent to inflict injury that causes physical harm or mental anguish. Sexual abuse was encompassed under that definition. A resident's cognitive status played a role and if the residents BIMS (Brief Interview for Mental Status, a screening tool used to assess cognition) score was low that meant there was no intent. When a sexual interaction occurred between residents without capacity the residents should be separated, must be assessed including a whole-body check. She was aware of Resident #2's criminal sexual status right after his admission to the facility and had contact with a detective who followed the resident. She could not state if the resident was registered in NYS, did not believe any contact had been made and she had not contacted any one legally about his continued sexual behavior. She stated, It would be the facilities responsibility to follow up with the resident predatory status. She did not feel abuse occurred with the incident on 3/26/2020 due to the resident's cognitive level meaning Resident #1 and 2 did not have capacity to consent. She was informed of the incident on 8/22/2020 by the DON that the residents did not remember what happened and she did not believe there was abuse. She stated Resident #1 and 2 should have been assessed on 8/22/2020 and the fact that the male resident was straddling Resident #1 an assessment should have been done of the resident's vaginal area. After the staff called the doctor if he said to call the police, they would follow that directive. The physician did not so they did not call police or send Resident #1 to the hospital for a rape assessment. The 15-minute checks should be completed per the plan of care and after review of the 8/22/2020 incident between residents #1 and 2 stated the checks were not completed. The social worker was assigned to follow up on mental health issues after an incident. During the incident on 3/14/2020 the psychologist was consulted, and recommendations included a stopwatch across the door. She recalled the recommendation of Resident #1 being moved off the unit and the family refused. She did not recall if they considered moving Resident #2 off the unit. If Resident #1 continued seeking behaviors she would expect the resident to be protected and additional steps should take place for prevention. On 10/19/2020 at 10:47 AM the Director of Social Services was interviewed via telephone and stated she was made aware Resident #2 was a sex offender on 5/27/2019. She did not recall who told her and thought all the people in charge were aware of the resident's sex offender status. She stated she felt the facility took appropriate measures to protect other residents in the facility from Resident #2 and could not state any specific interventions that were implemented. On 10/19/2020 The physician was interviewed via telephone at 11:03 AM, and stated he was not aware of Resident #2's sexual predator status. He was aware of some interactions between Residents #1 and 2 and if penetration occurred, he would expect the resident's vaginal area be assessed, and the police notified. He was not made aware penetration occurred. He would expect the residents involved to be separated and alarms be used. If interaction continued between the residents, with Resident #2's history, they should not be in the same facility. On 9/10/2020 at 10:10 AM, Resident #2 was observed sitting in the wheelchair in their room (Unit #1). Resident #2 did not respond verbally when the surveyor tried to speak with them. On 9/10/2020 from 12:07 PM to 12:30 PM, Resident #1 was observed wandering on Unit #2. The resident was not able to be interviewed by the surveyor. 10NYCRR 415.4(b)(1)(i)

Plan of Correction: ApprovedNovember 23, 2020

I. The following corrective actions were accomplished for the residents found to have been affected by the deficient practice:
? Resident # 4
o No longer at the facility.
a. A medical record review has been completed to ensure all improvement opportunities related to abuse, specifically sexual abuse, have been identified and addressed in this plan of correction
? Residents # 1 & 3
o RN assessments have been completed
o Psych evaluation has been completed
o The Sexually, physical, verbally aggressive risk assessment has been completed
o Behavior Care plans have been updated to reflect potential to be abused based on risk assessment
o Residents #1 and #3 will not be placed on the same unit as resident #2. Care plan and C.N.A. care card has been updated accordingly.

? Resident # 2
o Psych evaluation has been completed
o The Sexually, Physical, Verbally Aggressive Risk Assessment has been completed and behavioral care plan and C.N.A. care card have been reviewed and revised with interventions that include activities of his liking.
o All staff educated on CCP related to inappropriate sexual behavior including monitoring, staff supervision and redirection.
? Counseling and Education:
o DON, SW and Administrator have been counseled and re-educated regarding sexual abuse, specifically, identification, assessment, and reporting requirements
o DON has been counseled and re-educated on ensuring that resident?s who require 1:1, Q15 or Q30 min observations have been reviewed to ensure that services have been provided and documentation is in place to support.
o Social Worker, Director of Nursing and Administrator educated on the Abuse Critical Element pathway (CEP ) as it relates to investigating an alleged violation of abuse and implementing safeguards to prevent further potential abuse.


II. All residents have the potential to be affected by the deficient practice.
? The following corrective actions will be taken:
o Administrator and Director of Nursing have reviewed the past 30 days of Accident and Incident Reports, to ensure all incidents of abuse, specifically, sexual abuse and have been identified, thoroughly investigated, include an RN assessment, and have been reported to local law enforcement, if applicable

o Director of Nursing/Designee have reviewed all residents in the past 30 days which have been placed on 1:1 supervision, Q15 or Q30 minute observation to ensure that services have been provided and documentation is in place to support.
o A Sexually, physical, verbally aggressive risk assessment has been completed on all residents with care plans developed based on results of assessment.

III. In an effort to ensure deficient practice does not recur, the following systemic changes will be put in place:
? Abuse policy has been reviewed and revised, specifically to include reporting under the Elder Justice Act
o All staff have been educated on this policy with emphasis on understanding what constitutes sexual abuse and requirements for reporting timely
o All nurses have been educated on this policy as it relates to ensuring that an RN assessment is completed with any witnessed or suspected sexual abuse
o RN assessment will determine the need for hospital transport for further evaluation and treatment
a. Following an RN assessment s/p alleged non consensual sexual contact revealing physical injuries to intimate body parts (i.e. vaginal, rectal, breast) including bruises in the areas of inner thighs, the MD will be notified and arrangements will be made to send the resident to the Hospital for further evaluation and treatment.
o All nurses have been educated on this policy to ensure all incidents of abuse, specifically, sexual abuse, have been identified, thoroughly investigated, and reported to local law enforcement, if applicable.
? Resident # 1 resides on 2nd floor. Resident # 2 resides on 1st floor. Upon return from hospitalization , the risk indicator for sexually , verbally, and physically aggressive episodes will be completed and care plan findings based on the assessment.
? Resident # 2's CCP will be reviewed with all staff including new hires to ensure they are knowledgeable and competent in how to care for resident. Any changes in the CCP will be reviewed by the IDT and shared with all staff. C.N.A. care card will be updated accordingly.
? Special Assignment Observation Policy has been newly adopted
o All nursing staff will be educated on the new policy, specifically to ensure that required observations have been completed and documented.
? The Sexually, physical, verbally aggressive Policy has been newly adopted.
o All staff have been educated on this policy, specifically as it relates to their responsibility to report any potential sexual behaviors or expressions of intimacy to supervisor/designee.
o All nurses, social worker, admissions director, director of nursing and administrator will be educated to complete the Sexually, Physically, Verbally, Aggressive risk assessment on all residents upon admission, re-admission and upon report of any new behaviors, (i.e. interest for sexual intimacy, ability to consent to such relations, attempted physical contact). Behavior care plan and C.N.A care card will be updated accordingly.
o The social worker will meet with high risk residents and document their preferences and sexual boundaries and initiate a CCP based on findings.
o Interdisciplinary Team will participate in the care planning process and review all new behaviors, including interest for sexual intimacy to determine individual resident capacity and establish boundaries and care plans.
o Direct care staff will be educated on each of these care plans and C.N.A. care card will be updated accordingly.


IV. The facility compliance will be monitored utilizing the following quality assurance system:
? Accident and Incident reports will be audited weekly by the Administrator/Designee for three (3) months to ensure that all incidents of suspected or reported sexual abuse have been identified, thoroughly investigated, include an RN assessment, and have been reported to local law enforcement, if applicable
? Residents receiving 1:1 supervision, Q15 or Q30 minute observation will be audited by the Director of Nursing/Designee weekly x three (3) months to ensure that services have been provided and documentation is in place to support.
? All new admissions and re-admissions will be audited weekly by the Administrator/Designee for three (3) months to ensure that a Sexually, Physical, Verbally Aggressive Risk Assessment has been completed with behavior care plans and C.N.A. care card developed based on results of assessment
? Progress notes will be audited weekly by the Director of Nursing/Designee for three (3) months to ensure that any incidents of potential sexual behaviors or expressions of intimacy have received an IDT review and care plans and C.N.A. care card have been updated accordingly.
? Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.

Responsible Party: Administrator and Director of Nursing

FF11 483.12(b)(5)(i)-(iii):REPORTING OF REASONABLE SUSPICION OF A CRIME

REGULATION: §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 19, 2020
Corrected date: December 1, 2020

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during abbreviated surveys (NY 348, NY 801 and NY 670), the facility did not ensure the reporting of crimes occurring in federally-funded long-term care facilities for 2 of 4 residents reviewed (Residents #1 and 2), Specifically, Resident #1 was sexually abused by Resident #2 on two occasions and the facility did not report reasonable suspicion of a crime against an individual receiving care in the facility to law enforcement as required. Findings include: The 3/21/2019 facility Abuse policy documented all residents will be protected from abuse, neglect, mistreatment, sexual coercion, or assault. The policy addressed criteria for reporting abuse incidents to the NYS Department of Health (NYS DOH) and did not address criteria for reporting incidents to law enforcement. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The 8/4/2020 MDS documented the resident's cognition was severely impaired. Resident #2 had [DIAGNOSES REDACTED]. The 5/1/2019 MDS assessment documented the resident had no short or long-term memory impairment and was independent with decision making. Resident #2's discharge instructions from the skilled nursing facility the resident was admitted from dated 5/24/2019, documented the resident was discharged because his needs could not be met. The resident was at high risk for heterosexual behavior and exposed his penis to others. Resident #2's comprehensive care plan (CCP) dated 5/24/2019 documented the resident had potential to abuse others. Interventions included to monitor frequently, update medical providers with any changes, and provide 1:1 activity. A 5/29/2019 note, written by the Administrator, documented after admission, she became aware Resident #2 was a known sexual predator from another state and on 5/25/2019, the resident took a non-consenting female into his room. Resident #2 was being sent out for an evaluation due to seeking out Resident #3. The 3/26/2020 facility incident summary documented; - Resident #2 was found on Resident #1's bed. Resident #1 was unclothed and Resident #2 had his hand inside Resident #1's vagina. - The plan was for 15-minute checks and Resident #2 was to be moved to Unit 1 and have a motion detector on his door. - CNA #5's statement dated 3/26/2020 and included in the facility investigation, documented she found Resident #1 lying on the bed without clothes on and Resident #2 had his whole fist inside of Resident #1's vagina. She told Resident #2 to stop and made the resident leave the room. She notified a Supervisor. The Director of Social Services was interviewed on 9/10/2020 at 1:18 PM, and stated she was informed of the incident between Residents #1 and 2 on 3/26/2020 at approximately 6:00 PM by LPN #1. She went to the unit and saw Residents #1 and 2 had been separated and were by the nursing station. She contacted the Administrator and the DON. She stated Resident #1 had advanced dementia and would not be able to make an informed decision. She talked to Resident #2 the following day and he denied touching Resident #1. She provided education to Resident #2 again not to enter female resident's room. The police were not notified, and Resident #1 was not sent to the hospital for evaluation. She stated she did not feel abuse, neglect or mistreatment occurred as the residents had cognitive impairment and there was no intent. Director of Nursing (DON) #6 was interviewed via phone on 9/21/2020 at 9:54 AM and stated she worked at the facility from (MONTH) 2020 to mid-April 2020. She stated she was notified at home on 3/26/2020 of the incident between Residents # 1 and 2. She directed the staff to provide 1:1 for Resident #2 while he remained on the unit and he was to be relocated to another unit. Resident #1 was to be placed on 15-minute checks. Once Resident #2 was moved to Unit 1 he was to be monitored every 15 minutes. She did not call the police and report the incident and did not recall what she concluded in the investigation. The incident report was reviewed with DON #6 and she stated she did not feel abuse occurred as both residents had a [DIAGNOSES REDACTED]. Registered nurse (RN) #10 was interviewed on 10/6/2020 at 1:17 PM and stated she was notified by licensed practical nurse (LPN) #9 on 8/22/2020 of the incident between Residents #1 and 2. She was told Resident #2 was positioned over Resident #1 and Resident #1's attends (adult brief) were pulled down below the vaginal area. Resident #2 was straddled over Resident #1. By the time she arrived on the unit 2-3 minutes later, Resident #1 was in her room and Resident #2 was in his room. She went to see Resident #1 and she observed the resident fully dressed siting on the bed, confused. She asked the resident how she was, and the resident stated she was okay and he did what he did. She asked Resident #1 what she meant, and the resident stated his hands were there and she pointed to her private parts. She then when to see Resident #2, she looked at him and did not notice anything in particular. Resident #2 was sitting in a chair with a sheet over him. She stated, that was that. She completed her note and signed that she assessed the residents. She did not look at the resident's body parts including Resident #1's vaginal area because she was told nothing happened and the residents were separated. She did not notify the police. DON #7 (the facility's current DON) was interviewed on 10/6/2020 at 2:00 PM and stated she started in the position in 6/2020. Her role included conducting the investigation, summarizing findings, reviewing the incident with the interdisciplinary team, and determining what is reportable to the NYS DOH. She did not feel Residents #1 or 2 could consent to sexual activity. She stated if she suspected abuse, she would expect the police to be notified at the time of the incident and she did not feel abuse occurred in the 8/2020 incident. Looking back at the 3/26/2020 incident, she stated she thought abuse did occur and the police should have been called. She concluded the incident on 8/22/2020 was reportable to the NYS DOH due to the inappropriate contact between residents however no abuse occurred as the residents did not willfully intend to cause harm and the residents did not have the capacity to consent. The Administrator was interviewed on 10/6/2020 at 2:40 PM and stated she had been in the position since (MONTH) 2019. She defined abuse, according to the facility policy, as the willful intent to inflict injury that causes physical harm or mental anguish. Sexual abuse was included in that definition. Cognitive status played a role and if the residents BIMS (Brief Interview for Mental Status) score was low that meant there was no intent. She was not sure if the police should have been notified after the 3/26/2020 incident and did not feel abuse occurred due to the residents' cognitive level as they could not consent. She was informed of the incident on 8/22/2020 by the DON. The residents did not remember what happened and she did not believe there was abuse. She stated after the staff called the doctor, if he said to call the police, they would follow that directive. The physician did not so they did not call police. On 10/19/2020, the physician was interviewed via telephone at 11:03 AM, and stated he was aware of some interactions between Residents #1 and 2 and if penetration occurred, he would expect the police to be notified. He stated he was not made aware that penetration occurred during the 3/26/2020 incident and was not aware penetration may have occurred in the 8/2020 incident. 10NYCRR 415.4

Plan of Correction: ApprovedNovember 23, 2020

I. The following corrective actions were accomplished for the residents found to have been affected by the deficient practice:
? Resident # 2
o Oswego City Police Department notified of incident.
? Resident # 1
o Has been evaluated by Social Services for adverse psychological effects related to sexual abuse
? DON, SW and Administrator have been counseled and re-educated regarding sexual abuse, specifically reporting requirements to local law enforcement

II. All residents have the potential to be affected by the deficient practice.
? Administrator and Director of Nursing have reviewed the past 30 days of Accident and Incident Reports, specifically to ensure all incidents of abuse, specifically, sexual abuse has been reported to local law enforcement, if applicable

III. To ensure deficient practice does not recur, the following systemic changes will be put in place:
? Abuse policy has been reviewed and revised, specifically to include reporting any actual or suspected abuse, specifically sexual abuse, to local law enforcement per the Elder Justice Act
o All staff have been educated on this policy to ensure all incidents of abuse, specifically, sexual abuse, are reported to local law enforcement.

IV. The facility compliance will be monitored utilizing the following quality assurance system:
? Accident and Incident reports will be audited weekly by the Administrator/Designee for three (3) months to ensure that all incidents of suspected or reported sexual abuse have been reported to local law enforcement, if applicable
? Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results.

Responsible Party: Administrator

FF11 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 19, 2020
Corrected date: December 1, 2020

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during abbreviated surveys (NY 348, NY 801 and NY 670), the facility did not provide or arrange services that met professional standards of quality for 2 of 4 residents reviewed (Residents #1 and 2). Specifically, Resident #1 was not assessed by a qualified professional after being sexually abused by Resident #2. Findings include: The 5/10/2019 Incident/Accident policy documented all incident/accidents will be reported and report forms completed timely. The Administrator was responsible for ensuring a thorough and timely investigation to rule out abuse, neglect, and mistreatment, and implementation of individualized interventions to prevent reoccurrence. When an incident occurred, a nursing assessment will be completed for all residents and documented on the facility incident report and in the nursing progress notes. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The 8/4/2020 MDS documented the resident's cognition was severely impaired. Resident #2 had [DIAGNOSES REDACTED]. The 5/1/2019 MDS assessment documented the resident had no short or long-term memory impairment and was independent with decision making. The 3/26/ 2020 facility incident summary documented; - Resident #2 was found on Resident #1's bed. Resident #1 was unclothed and Resident #2 had his hand inside Resident #1's vagina. - Certified nurse aide (CNA) #5's statement dated 3/26/2020 and included in the facility investigation documented she found Resident #1 lying on the bed without clothes on and Resident #2 had his whole fist inside of Resident #1's vagina. She told Resident #2 to stop and made the resident leave the room. She notified a Supervisor. - There was no documented evidence Resident #1 was assessed by a qualified professional following the incident. Licensed practical nurse (LPN) #1 was interviewed on 9/10/2020 at 2:48 PM and stated she worked on 3/26/2020 on the 7:00 AM to 3:00 PM shift and then on the 3:00 PM to 11:00 PM shift. She stated when she was notified of the incident, she notified the Director of Social Services for further guidance. The residents were separated, and Resident #2 was placed on 15-minute checks and moved to Unit 1. She stated Resident #1 had severe dementia and Resident #2 had mental health issues. The facility incident/accident report dated 8/22/2020 documented at 3:15 PM, Resident #2 was found straddling Resident #1 on his bed. Resident #2 was observed half naked. Resident #1's pull up (incontinence brief) was just off the hips. Resident #1 stated you caught us just in the nick of time. The residents were separated. The 8/22/2020 resident to resident summary of abuse documented at approximately 3:15 PM CNAs #5 and 7 entered Resident #2's room, the door was closed, and they observed Resident #1 lying on Resident #2's bed with her brief pulled down on her hip. Resident #2 was naked from the waist down and kneeling over Resident #1 with his knees on the bed. The residents were separated and Resident #2 stated he did what he did. Resident #2 reported his hands were there while pointing to Resident #1's genital area. Resident #2 was moved to Unit 1 and placed on 10-minute checks. Director of Nursing (DON) #6 was interviewed via telephone on 9/21/2020 at 9:54 AM, and stated she worked at the facility from (MONTH) 2020 to mid-April 2020. She stated she was notified at home on 3/26/2020 of the incident between Resident # 1 and 2. She did not recall if she came into the facility on the evening of the incident or if she assessed Resident #1. She stated if she did an assessment, it would be documented. Registered nurse (RN) #10 was interviewed on 10/6/2020 at 1:17 PM, and stated she was notified by LPN #9 on 8/22/2020 of the incident between Residents #1 and 2. She was told Resident #2 was positioned over Resident #1 and Resident #1's attends were pulled down below the vaginal area. Resident #2 was straddled over Resident #1. By the time she arrived on the unit, 2-3 minutes, later Resident #1 was in her room and Resident #2 was in his room. She went to see Resident #1 she observed the resident fully dressed sitting on the bed confused. She asked Resident #1 how she was, and the resident stated she was okay and he did what he did. She asked Resident #1 what she meant, and the resident stated his hands were there and she pointed to her private parts. She then when to see Resident #2, she looked at him and did not notice anything in particular. Resident #2 was sitting in a chair with a sheet over him. She completed a progress note and signed that she assessed the residents. She did not look at either residents' body parts including Resident #1's vaginal area. DON #7 was interviewed on 10/6/2020 at 2:00 PM and stated she was not present at the time of the incident and was made aware of the incident from the LPN charge nurse while at home. An assessment was to be completed after an incident with suspected injury and included a set of vitals signs, identifying any physical injury, bumps, redness, skin issues or emotional state including distress. In the case of the incident Between Residents #1 and 2 on 8/22/2020 she expected a head to toe assessment be completed on the residents at the time of the incident and she was not aware an assessment was not completed. The Administrator was interviewed on 10/6/2020 at 2:40 PM and stated when a sexual interaction occurred between residents without capacity the residents should be separated and must be assessed including a whole-body check. She stated Residents #1 and 2 should have been assessed on 8/22/2020. She stated because the male resident was straddling Resident #1 an assessment should have been done of the Resident #1's vaginal area. On 10/19/2020 the physician was interviewed via telephone at 11:03 AM, and stated he was aware of some interactions between Residents #1 and 2 and if penetration occurred, he would expect the residents vaginal area to be assessed. He was not made aware penetration occurred on 3/26 or that it possibly occurred in 8/2020. 10 NYCRR 415.11 (a)(3)(ii)

Plan of Correction: ApprovedNovember 23, 2020

I. The following corrective actions were accomplished for the residents found to have been affected by the deficient practice:
? Resident # 4
o No longer resides at the facility.
1. A medical record review has been completed to ensure all improvement opportunities related to abuse, specifically sexual abuse, have been identified and addressed in this plan of correction
? Residents # 1, 2 & 3
o RN assessments have been completed
? Director of Nursing have been counseled and re-educated to ensure RN assessments are conducted for any resident identified as being sexually abused

II. All residents have the potential to be affected by the deficient practice.
? Administrator and Director of Nursing have reviewed the past 30 days of Accident and Incident Reports, specifically to ensure all incidents of abuse, specifically sexual abuse, include an RN assessment

III. In an effort to ensure deficient practice does not recur, the following systemic changes will be put in place:
? The Accident and Incident Policy and Procedure was reviewed without revision.
o All nurses have been re-educated on this policy as it relates to ensuring that an RN assessment has been completed with any report or suspicion of abuse, specifically, sexual abuse.
? Abuse policy has been reviewed and revised to include specific criteria related to RN assessment following a sexual abuse incident.
o All nurses have been educated on this policy as it relates to ensuring that an RN assessment is completed with any witnessed or suspected sexual abuse
o RN assessment will determine the need for hospital transport for further evaluation and treatment.
a. RN assessment will be completed and documented on the facility incident report and progress notes to include vital signs, identification of physical injuries, and in the event of alleged sexual abuse; assessment of intimate body parts for evidence on non-consensual sexual intrusion or penetration.

IV. The facility compliance will be monitored utilizing the following quality assurance system:
? Accident and Incident reports will be audited weekly by the Director of Nursing/Designee for three (3) months to ensure that all incidents of suspected or reported sexual abuse include an RN assessment

Responsible Party: Director of Nursing