Other·July 9, 2021

F600 42 CFR 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. The facility failed to ensure residents remained free from abuse when: 1) The facility did not investigate or care plan one resident's (Resident 1) behavior of wandering into other residents' rooms before 7/29/19 or provide supervision to Resident 1 after staff observed the behavior. This resulted in Resident 1's sexual abuse of another resident (Resident 2). 2) The facility did not implement its Abuse & Neglect Prohibition policy, when the facility learned of a sexual abuse allegation against one resident (Resident 4) but did not investigate the allegation or make the facility's abuse coordinator aware of the allegation for three days. This failure provided Resident 4 the opportunity to potentially abuse additional facility residents. 3) The facility did not care plan to manage one resident's (Resident 4) sexual behavior toward facility residents of the opposite sex. This failure did not meet Resident 4's sexual expression and psychosocial needs, and did not ensure the environment of care was safe and free from abuse when six residents (Resident 5, 6, 8, 9, 10, and 11) vocalized concerns for safety and anger based on alleged unwanted sexual contacts by Resident 4 or observing Resident 4's behaviors. On 7/30/19, at 1:00 p.m., an unannounced visit was conducted at the facility to investigate allegations of abuse. 1. A review of Resident 1's Face Sheet (a document in the medical record containing basic medical and socioeconomic data) indicated Resident 1 had a medical history of cerebral infarction (stroke), unspecified psychosis (impairment of thoughts and emotions), disorientation, and substance use disorder, and behavioral history of aggressiveness, elopement, and wandering. A review of Resident 1's most current MDS (Minimum Data Set, an assessment tool) indicated Resident 1 achieved a summary score of 7 on a brief interview for mental status (BIMS) from 5/7/19, indicating severe cognitive impairment (impairment indicating severe decline of mental function). Resident 1's MDS indicated the resident required "supervision" with most activities of daily living and could ambulate without an assistive device. During an interview on 7/30/19, at 3:00 p.m., Resident 1 stated he recalled the sexual abuse incident with Resident 2. Resident 1 stated "It was quite entertaining for me." Resident 1 stated he recalled "fondling" and "feeling" Resident 2's penis and stated, "It was entertaining and very exciting." A review of Resident 2's Face Sheet indicated Resident 2 had a medical history of cerebral hemorrhage (stroke) with left-sided weakness, difficulty walking, and major depressive disorder. A review of Resident 2's most current MDS indicated Resident 2 achieved a summary score of 10 on a BIMS from 5/13/19, indicating moderate cognitive impairment (impairment of the mind, between one's expected mental decline with age and severe decline of mental function). Resident 2's MDS also indicated the resident used a wheelchair to move about the facility and was dependent on at least two staff for assistance when repositioning in bed. During an interview on 7/30/19, at 3:30 p.m., Resident 2 stated he recalled Resident 1 touching Resident 2's penis and underneath his brief. Resident 2 stated Resident 1's touching was unwanted. Resident 2 stated "30" minutes passed between when Unlicensed Staff B separated Residents 1 and 2, and when Licensed Staff C visited Resident 2 to assess the resident following the incident. During an interview on 7/30/19, at 1:35 p.m., Unlicensed Staff B stated she observed Resident 1 abuse Resident 2 on the morning of 7/29/19, at "8:45 a.m." Unlicensed Staff B stated she was assigned to Resident 2's care that morning. She stated when she entered Resident 2's room to "get some diapers" for a resident in another room, she noticed Resident 2 waving for attention. Unlicensed Staff B stated she walked toward Resident 2 and found Resident 1 at Resident 2's bedside. Unlicensed Staff B stated Resident 1's hand was inside Resident 2's gown and blankets, and Resident 1's hand was moving up-and-down at or around Resident 2's genitals. Unlicensed Staff B stated she separated Residents 1 and 2 and notified the charge nurse. Unlicensed Staff B stated she did not recall what the charge nurse initially told her; however, "sometime later," the charge nurse (Licensed Staff C) "told me to finish [morning hygiene], and then tell the administrator" about the incident. Unlicensed Staff B stated that after informing Licensed Staff C of the incident, she completed her prior task, washed her hands, and then initiated morning hygiene with Resident 2. Unlicensed Staff B stated she knew Resident 1 had touched Resident 2's penis and genitals because Resident 2's penis was outside the resident's brief when she performed Resident 2's morning hygiene. During an interview on 7/30/19, at 1:08 p.m., Administrator stated on the morning of 7/29/19, at 8:45 a.m., Unlicensed Staff B "came to me" and "reported" seeing Resident 1 sexually abusing Resident 2. Administrator stated Unlicensed Staff B observed Resident 1 standing over Resident 2, handling Resident 2's genitalia. Administrator stated she was the facility's abuse coordinator. Administrator stated that Unlicensed Staff B reported the observation to Administrator immediately after Unlicensed Staff B reported to the "charge nurse." During an interview on 7/30/19, at 1:45 p.m., Unlicensed Staff B stated she was assigned to care for Resident 2, at the time of the incident. Unlicensed Staff B stated she did not know Resident 1 posed a safety risk on the morning of the incident, 7/29/19. Unlicensed Staff B stated she did not pay attention to the safety risk posed by residents to which she was not assigned. Unlicensed Staff B stated: "I have a habit to just get my report. I do my patient." She stated: "I do not" listen for safety concerns mentioned about other residents. During an interview on 7/30/19, at 2:00 p.m., Licensed Staff C stated she had no recollection of Resident 1's wandering behavior but stated that Resident 1 would "just walk and not go into rooms." During an interview on 7/30/19, at 2:35 p.m., Licensed Staff D stated she was aware of Resident 1's wandering behavior. Licensed Staff D stated Resident 1 "goes in-and-out of his room," and was out of his room "frequently." During an interview on 7/31/19, at 5:34 p.m., Social Service Director (SSD) stated she observed Resident 1 seated inside Resident 2's room at the bedside between 7/20/19 and 7/29/19. SSD stated she observed Resident 1 sitting on Resident 2's wheelchair and recalled Resident 2 did not want Resident 1 there. SSD stated she notified Licensed Staff E of her observation. SSD stated Resident 1 had a history of wandering outdoors through sliding doors. SSD stated Resident 1 wandered into Resident 2's room because that room had a sliding door. SSD stated Resident 1 liked sliding doors. SSD stated the facility moved Resident 1 in early July into a room without a sliding door because of Resident 1's wandering and elopement risk. During an interview on 7/31/19, at 6:40 p.m., Resident 2 stated Resident 1 had been inside Resident 2's room days before the abuse. Resident 2 stated Resident 1 sat in Resident 2's wheelchair at the resident's bedside. Resident 2 stated the Social Services Director removed Resident 1 on that occasion. During an interview on 8/5/19, at 11:35 a.m., Licensed Staff E stated she was a unit manager at the facility. Licensed Staff E stated she recalled "good" communication with the SSD concerning residents' needs. Licensed Staff E stated she recalled SSD sharing information about Resident 1's wandering days prior to the witnessed sexual abuse incident, but she could not recall the detail SSD shared. Licensed Staff E stated Resident 1 "could have" been inside Resident 2's room but was not certain. During an interview on 8/20/19, at 11:02 a.m., Licensed Staff D stated nursing supervised Resident 1's elopement and wandering behaviors prior to the 7/29/19 incident through "general nursing rounds." Licensed Staff D stated nursing did not place Resident 1 on "heightened" supervision until the incident of abuse because Resident 1 was "not going into other resident rooms." During a review of Resident 1's medical record, the Care Plan for "Behavioral Symptoms," dated 4/23/18, indicated Resident 1 exhibited "searching behaviors" and had a history of wandering out of the facility. During a review of Resident 1's medical record, the Progress Notes, dated 7/3/19, indicated Resident 1 "needs to be" in a room with "no sliding door," because the resident "has a behavior of wandering." During a review of Resident 1's medical record, no care plans indicated a plan to manage the potential for Resident 1's searching behavior to bring Resident 1 into other residents' rooms with a sliding door. The facility policy and procedure titled "Resident Elopement," released 8/5/01, indicated the policy concerned residents "attempting to leave the premises, or suspected of being missing ...." The policy did not indicate how the facility managed residents who wandered in the facility without leaving the premises or going missing. The facility maintained no policy and procedure to standardize a process for managing patients with a history of wandering (behaviors of repetitive walking or similar movement, which is inconsistent with boundaries, limits, or obstacles, and which expose a resident to harm). The facility guideline titled "Guidelines in Monitoring of Residents," dated 05/2013, indicated it was used "for safety," generally. The guidelines indicated only the facility's Interdisciplinary Team (IDT) may institute one-to-one monitoring. The guidelines indicated "one-on-one monitoring" required more supervision than "close supervision," which required physical relocation of the resident to areas "monitored by staff." The guidelines did not define one-to-one monitoring. The guidelines did not indicate the duties for one-to-one monitoring. 2. During an interview on 7/30/19, at 1:08 p.m., Administrator stated the facility Administrator was the facility's Abuse Coordinator. During an interview on 8/16/19, at 12:30 p.m., Administrator stated she was present in the facility on 8/2/19, when Resident 6 vocalized concern to a charge nurse about the behavior of a male resident in the facility. Administrator stated the facility moved Resident 6 to another room on 8/2/19, between "5:00 p.m. and 6:00 p.m.," during the "PM" shift. A review of Resident 6's Face Sheet indicated Resident 6 had a medical history of spinal cord damage, traumatic brain injury, multiple broken bones, quadriplegia (paralysis of all four limbs), borderline personality disorder and bipolar disorder (psychiatric disorders affecting mood and social behaviors). A review of Resident 6's most current MDS (Minimum Data Set, an assessment tool) indicated Resident 6 achieved a summary score of 12 on a brief interview for mental status (BIMS) from 5/21/19, indicating moderately impaired cognitive ability (impairment of the mind, between one's expected mental decline with age and severe decline of mental function). During an observation and interview on 8/16/19, at 2:35 p.m., Resident 6 was seated in a common area alongside a mental health caseworker. Resident 6 stated about "six weeks ago" Resident 4 stood in Resident 4's doorway and made a sexual hand gesture in Resident 6's direction. Resident 6 stated the hand gesture comprised of Resident 4 sticking his index finger of one hand into a hole, created by the index finger and thumb of Resident 4's other hand. Resident 6 stated she was admitted to a room across the hallway from Resident 4 at the time. Resident 6 stated she witnessed this gesture while lying in bed and talking on the phone. Resident 6 stated the gesture made her feel "really, really offended." Resident 6 stated she told Resident 4 to "Stop that," after which Resident 4 turned and closed Resident 4's door. Resident 6 stated Resident 6's door was open because someone who had been inside her room earlier had forgotten to close it. Resident 6 stated she was "pretty big about keeping the door closed now." After the incident, Resident 6 stated the facility moved her to different hallway, away from Resident 4, on Resident 6's request. During an interview on 9/4/19, at 12:45 p.m., Family Member R stated Resident 6 informed Family Member R of an incident when a facility resident located "across the hall" from Resident 6 had made a sexual hand gesture toward Resident 6. Family Member R stated the facility had since "moved [Resident 6] away from" that resident "and placed [Resident 6] somewhere else." Family Member R stated he believed Resident 6 was currently safe. Family Member R stated Resident 6 has episodes of "mania" (a mental disorder characterized by excessive excitement), during which the resident vocalized issues that were "nothing" of concern. Family Member R stated when the resident exhibited mania, "investigation is required to determine whether something is right or wrong." During a review of the clinical record for Resident 6, the "Resident Progress Notes," dated 8/2/19, at 5:52 p.m., indicated Resident 6, "[v]erbalized seeing someone in the room, constantly yelling." The nurse who documented the progress note "redirected [Resident 6], but [Resident 6] insisted on moving room[s]. ... Room change done." During a review of the clinical record for Resident 6, the "Resident Progress Notes," dated 8/5/19, at 2:30 p.m., indicated "[Resident 4] made a gesture with his hand to [Resident 6]," and "[Resident 6] was not offended" and "[could] not recall anything" about the incident. The progress note indicated it was a "Late Entry," entered into Resident 6's medical record on "08/09/2019," seven days after the incident and one day after the facility notified CDPH of the incident, on 8/8/19. During a review of the clinical record for Resident 6, the "Care Plan," updated by MDS Coordinator on 8/19/19, at 12:25 p.m., indicated the facility planned to manage Resident 6's "hallucination" from "8/2/19." The care plan indicated on "8/2/19" Resident 6 "insisted on seeing another person (male) in her room." The care plan indicated staff "immediately checked at that moment" but did not observe a male resident in Resident 6's room at that time. The care plan indicated the facility would take the several "approach[es]" to manage the residents psychiatric and behavioral health needs, including to "identify issues that may trigger behavioral manifestations." The facility's "Investigation Summary" of the incident between Residents 4 and 6, dated 8/15/19, indicated the facility learned about Resident 4's behavior on or before "8/2/19," a Friday. On the same day, the facility facilitated a room change for Resident 6 because "the resident" desired to be away from a gesturing "male resident." The report indicated on 8/2/19 Resident 6 initially reported a concern about the male resident to the "charge nurse." The facility policy and procedure titled "Abuse & Neglect Prohibition," revised October 2004, indicated "Each resident has the right to be free from ... abuse ...." The policy indicated the definition of "Abuse" as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish." The policy indicated the definition of "Sexual abuse" includes "sexual harassment." The facility policy indicated "facility supervisors will immediately correct and intervene in reported or identified situations in which abuse ... is at risk for occurring." The policy indicated "The facility will conduct an investigation of any alleged abuse ... in accordance with state law." The policy indicated "the facility will protect residents from harm during the investigation." The facility policy and proce