Other·December 29, 2021

Class A Citation CFR (Code of Federal Regulations) 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. 22 CCR 72527. Patients' Rights. (a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 10/8/2020 at 1:16 p.m., an unannounced visit was conducted at the facility to investigate an entity reported incident, CA00707973 regarding Resident 2's sexual abuse that occurred on 10/6/2020. Resident 2 was sexually abused and experienced unwanted oral copulation (any contact, no matter how slight, between the mouth of one person and the sexual organ or anus of another person) and finger penetration (the act of inserting an object of body part into another) by Resident 1 on 10/6/2020. This resulted in Resident 2's transport to the acute care hospital (ACH) to have the Sexual Assault Response Team (SART) (a medical-legal examination given to a survivor after a sexual assault has taken place) examination done on 10/7/2020. Resident 2 experienced fear, increased episodes of hallucinations, vaginal pain, and flash backs (sudden involuntary recurrent memory) of sexual assault. Resident 2 required additional anxiolytic (medications used to prevent and treat anxiety disorders) medications by prescribing psychiatrist on 10/12/2020 and an increase in dosage of anxiolytic medication on 11/9/2020 for suicidal ideation (wanting to take your own life) with episodes of panic attacks. The facility failed to ensure the safety and to protect residents from sexual abuse, and nursing staff failed to develop and implement effective interventions to address Resident 1's sexual behaviors toward Resident 2 on 9/24/2020 to ensure Resident 2's safety. The nursing staff failed to recognize, intervene, and report the alleged sexual abuse on 10/6/2020 within two hours of alleged sexual abuse. The Interdisciplinary team (IDT) (a facility group composed of a physician, a registered nurse, a social worker and additional appointed facility staff) did not evaluate and revise Resident 2's consensual sexual consent (an agreement to participate in a sexual activity, both people must agree to sex every single time) to protect the resident from sexual abuse. Resident 2 was a 40-year-old female, admitted to the facility on 12/20/2017. Resident 2 had diagnoses that included: schizoaffective (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms like depression or mania-excitement manifested by mental and physical hyperactivity) disorder), post-traumatic stress disorder (an anxiety disorder that develops following frightening, stressful events), and major depressive disorder (a condition characterized by feelings of hopelessness and worthlessness). Resident 2 was cognitively intact and independent in decision-making during activities of daily living. During a review of Resident 2's face sheet dated 10/7/2020, the record indicated Resident 2 was admitted to the facility on 12/20/2017. Resident 2's diagnoses included schizoaffective, post-traumatic stress disorder, major depressive disorder. During a review of Resident 2's Minimum Data Set (MDS) dated 9/24/2020, indicated Resident 2 had BIMS of 15. The MDS BIMS document indicated Resident 2 was cognitively intact and independent in decision-making during activities of daily living. Resident 1 was a 49-year-old male, admitted to the facility on 4/11/2014. Resident 1 had diagnoses that included: schizophrenia (mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). Resident 1 was cognitively intact and independent in decision-making during activities of the daily living. During a concurrent interview and record review on 10/8/2020, at 1:26 p.m., with Director of Nursing Service (DNS) and Director of Staff Development (DSD), the DNS reviewed Resident 1's consent titled, "Sexually Active within the Facility - Resident Contract" dated 10/18/2018 which indicated, "...The facility will make any and all attempts to protect residents from sexual abuse and nonconsensual sex. If sexual abuse were to be suspected, facility abuse reporting policy will be followed." The document indicated Resident 1's consent signature dated 10/18/2018. The DNS reviewed Resident 2's consent titled, "Sexually Active within the Facility - Resident Contract" dated 10/18/2018 and reflected Resident 2's consent signature dated 10/18/2018. The DNS stated Resident 1 and Resident 2 consented for sexual activity on admission and the consents were not reviewed after admission. Resident 1 and Resident 2's IDT were reviewed and reevaluated by the attending psychiatrist on a monthly basis. The DSD stated Resident 2 was alert and coherent, active, independent, and stayed in a private room in the women's hallway (West wing) due to gender orientation (biologically female and self-identified as male). The DSD stated Resident 2 did not have a history of sexual relationships with other male or female residents in the facility.. The DSD stated Resident 1 and Resident 2 were sexual partners since 2018. During an interview on 10/8/2020, at 1:36 p.m., with the Administrator (ADM), the ADM stated he conducted the investigation regarding the alleged sexual incident between Resident 1 and Resident 2 on 10/7/2020. The ADM stated the Program Counselor (PC) 2 reported to the Nursing Department the alleged sexual incident occurred on 10/6/2020 at approximately 1 p.m. to 1:30 p.m. when Resident 1 went into Resident 2's room where Resident 2 laid on the bed for a nap. The ADM stated Resident 2 instructed Resident 1 to go away and Resident 1 did not listen. Resident 1 began kissing Resident 2. Resident 1 removed Resident 2's pants and proceeded to perform oral copulation and inserted Resident 1's finger into Resident 2's vagina. When done, Resident 1 left Resident 2's room. The ADM stated Resident 2 did not notify staff immediately about the incident; and at approximately 4 p.m. on the same day (10/6/2020) PC 1 noticed Resident 2 in the hallway and commented that Resident 2 did not look well. Resident 2 told PC 1 that Resident 1 was "bothering" him [Resident 2]. PC 1 assured Resident 2 that she would make the nursing staff aware and redirect Resident 1 from Resident 2. The ADM stated Resident 2 informed Certified Nursing Assistant (CNA) 2 on 10/6/20 that Resident 2 did not want Resident 1 in the room and CNA 2 reported to Licensed Vocational Nurse (LVN) 2. The ADM stated LVN 2 spoke to Resident 2 about the request of not wanting Resident 1 into the room and Resident 2 stated Resident 1 had been in the room and had a sexual encounter with Resident 2. The ADM stated LVN 2 did not think or describe the incident as an assault. The ADM stated LVN 2 described Resident 2 as calm and did not appear in distress. The ADM stated LVN 2 spoke with Resident 1 and Resident 1 stated he only kissed Resident 2. The ADM stated Resident 2 spoke to PC 2 on 10/7/2020 (the following day of the sexual incident) about the alleged rape by Resident 1 and PC 2 reported the incident to ADM and Nursing Department. The ADM stated following PC 2's report, the ADM conducted the formal investigation of the alleged sexual incident and reported the incident to local authorities and [local county] police department. The ADM stated the [local county] Police Officer (PO) came to the facility on 10/7/2020 at 8:20 p.m. and conducted investigative interviews with Resident 1, Resident 2 and nursing staff. The ADM stated the PO spoke to his supervisor and requested Resident 2's transport to [local county] SART for medical-legal examination. Resident 2 left the facility with two accompanying Certified Nursing Assistant (CNA) to [local county] hospital for examination. The ADM stated the PO arrested Resident 1 and transported to [local county] jail on 10/7/2020 at 11 p.m. The ADM stated Resident 2 returned to the facility following the exam and remained in the facility. During an interview on 10/8/2020, at 3 p.m., with the ADM, the ADM stated Resident 2 was interviewed on 10/7/2020 and made the ADM aware of the previous encounter on 9/24/2020 with Resident 1 which prompted the facility to interview LVN 1 about the incident. LVN 1 wrote an incident report for Resident 1 and Resident 2 dated 10/8/2020. The ADM stated Resident 2 had flat affect, appeared calm, articulate and highly functioning and Resident 1 had slow functioning level. During a review of Resident 2's social service note dated 10/7/2020, indicated Resident 2 was interviewed by Social Service Director (SSD) and ADM. The document reflected, "... Has there been past issues between the two of you [Resident 1 and Resident 2]? Res [Resident 2] yes this has happened before about two weeks ago ...and started rugging [rubbing] my feet and legs and then kissing me, when nursing staff came in I redirected him [Resident 1] away from me ... Res [Resident 2] stated, "No, he [Resident 1] never threatened me ...but I [Resident 2] was afraid he [Resident 1] would get violent with me ..." During an interview on 10/8/2020, at 3:07 p.m., with the DNS and DSD, the DNS stated Resident 1 and Resident 2 had a previous incident (two weeks prior to 10/6/2020) when Resident 1 entered Resident 2's room and kissed Resident 2. DNS stated LVN 1 witnessed Resident 1 was in Resident 2's room and LVN 1 redirected Resident 1 back to his room. LVN 1 advised Resident 2 to notify the nursing staff immediately if Resident 1 returned to the room anytime. The DNS stated LVN 1 did not document the incident in progress notes and did not update Resident 1 and Resident 2's care plan. The DNS stated the incident on 9/24/2020 could have been investigated and placed Resident 1 in behavior close monitoring check and could have placed Resident 1 in facility's denial of rights (a professional person in charge has reason to believe specific rights would cause injury to person or others, serious infringement (action of breaking an agreement) on the rights of others and a serious damage to the facility) to protect Resident 2. The DNS stated the incident on 10/6/2020 would have been prevented if the previous incident on 9/24/2020 was addressed and should have alerted nursing staff to monitor Resident 1 and Resident 2. The DSD stated all nursing staff were trained to report suspected abuse and incidents investigated. The DSD stated, " ...When report of abuse was escalated, we [nursing staff] put resident on one on one close watch monitoring to protect other residents." During a concurrent observation and interview on 10/8/2020, at 3:27 p.m., with Resident 2, in the ADM's office with the DSD, Resident 2 sat on a chair with a cuddled teddy bear. Resident 2 appeared calm and displayed constant eye contact. Resident 2 consented to the DSD's presence in the room during the interview. Resident 2 stated, "I had been in the facility for two years and from [previous county] .... I stayed in a single room and transgender." Resident 2 stated, "... On Tuesday [10/6/2020] at around 1 p.m. to 1:30 p.m. I was laying down in my room to get a nap when [Resident 1] came to my room. I asked him [Resident 1] to leave ... I need to go to sleep but [Resident 1] was persistent in kissing me in face, chin, lips, and went down to remove my pants and underwear. [Resident 1] rubbed my feet and legs." Resident 2 stated, "...I wanted to stand up but [Resident 1] pushed me back and started licking my vagina and when [Resident 1] was done [Resident 1] stood up and left the room ... walked away. I froze." Resident 2 stated, "...I felt depressed and not the first time ...this happened two weeks ago and I don't remember the date but [Resident 1] went to my room ...kissing, rubbing my feet and legs is the big thing... licking and kissing my vagina. I did not report to CNA, licensed nurses because I'm scared a lot and staff would react. [CNA 1] was aware of the incident. She [CNA 1] should have done something about it [incident on 9/24/2020]." During an interview on 10/8/2020, at 3:32 p.m., with Resident 2, in the ADM's office, Resident 2 stated, "...I did not press the call light last Tuesday [10/6/2020] because [Resident 1] grabbed and pushed me and I am afraid of him [Resident 1]. Resident 2 stated, "I met him [Resident 1] in 2017 and we did not argue ...we kissed before but no penetration of penis to vagina." Resident 2 stated, "On Tuesday [10/6/2020] at around 4 p.m. [PC 1] asked me if I am not feeling well. I explained to her [PC 1] that something happened to us with [Resident 1] and she [PC 1] said we [nursing staff] will keep an eye out to [Resident 1] ....[CNA 2] told [LVN 2] [assigned to Resident 2 on shift] and instructed me not to tell anybody what had happened between me and [Resident 1]." Resident 2 stated, "I felt angry and frustrated and... yes, I felt violated my right." Resident 2 stated, "I did not tell anyone until the next day, I told [PC 2] about the incident on Tuesday [10/6/2020]." During an interview on 10/8/2020, at 3:40 p.m., with Resident 2, in administrator's office, Resident 2 stated, "Rape is type of penetration and this is not normal ...I felt uncertainty and fear people ...noise ...I am shaking and escalated my feelings... I Have PTSD [post-traumatic stress disorder]." During a phone interview on 10/9/2020, at 2:56 p.m., with LVN 1, LVN 1 stated she was aware of previous incident on 9/24/2020 between Resident 1 and Resident 2 when she covered lunch time of another staff [unrecalled date] around 5 p.m. on the East hallway [opposite hallway of Resident 2]. LVN 1 stated she saw when Resident 1 knocked and entered Resident 2's room. LVN 1 stated Resident 1 did not wait to get permission from Resident 2 to enter the room. LVN 1 stated she instructed CNA 1 to check and follow Resident 1 in Resident 2's room and she [LVN 1] was not sure if Resident 2 was in the room. LVN 1 followed CNA 1 in the room and saw Resident 1 in Resident 2's room and asked him [Resident 1], "What are you doing here?" Resident 1 answered back and stated, "I am talking to my friend." LVN 1 stated she saw Resident 2 covered in sheets with a cuddled teddy bear laid on bed while Resident 1 was standing at the foot of Resident 2's bed. LVN 1 asked Resident 2, "Are you ok with [Resident 1] here?" LVN 1 stated Resident 2 replied, "No" and LVN 1 instructed Resident 1 to leave Resident 2's room because Resident 2 does not want you [Resident 1] here [Resident 2's room]. During a phone interview on 10/9/2020, at 3:08 p.m., with LVN 1, LVN 1 stated she did not document the incident on 9/24/2020 in the progress notes. LVN 1 stated, "I was not aware Resident 1 and Resident 2 had consensual (existing mutual consent) sexual relationship, if I could have known I would investigate further." LVN 1 stated she did not consider the incident alarming on 9/24/2020. LVN 1 stated, "Resident 2's demeanor did not change ... more than normal and seems okay with flat affect. If I see him [Resident 2] worried and nervous, I could have reported it." LVN 1 stated she did not see Resident 2 act nervous or affected about the incident on 9/24/2020. During a concurrent phone interview and record review on 10/12/2020, at 3:45 p.m., with LVN 2, LVN 2 stated he was assigned to Resident 2 on the evening of 10/6/2020. LVN 2 reviewed Resident 2's progress note dated 10/6/2020 at 5:44 p.m. which indicated, " ... Approximately at 1