Other·July 18, 2024

Health and Safety Code 1418.91. (a) (b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The Department determined during the investigation of a facility reported incident that the facility failed to report to the department an incident of suspected abuse of a patient (Patient 3) on 3/18/2024. A Licensed Nurse (LN 2) documented an incident of resident-to-resident sexual abuse when Patient 2 was seen in Patient 3's room grabbing and rubbing Patient 3's right breast at which time Patient 3 appeared shocked. LN 2 documented notifying Patient 3's family, MD, and the supervisor. A review of Patient 3's Medical Record on 4/22/2024, indicated the patient's diagnoses included, seizures (uncontrolled body movements), abnormality of gait and mobility, need for assistance with personal care, polyneuropathy (when nerves outside the brain and spinal cord become damaged), unspecified dementia (loss of brain function) and was pleasantly confused. The minimum data set (MDS- assessment), dated 3/19/2024, indicated the resident's brief interview for mental status (BIMS score - used to assess cognitive status) was 09. (A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and Oto 7 suggests severe impairment). A review of Patient 2 's "Alert note," dated 3/18/2024 at 11:45 p.m., indicated, "When RN passed by (Patient 3's room) RN noticed Patient 2 was grabbing and rubbing Patient 3's right breast. RN stopped Patient 2 's behavior right away and examined Patient 3 if with injuries. Patient 3 appeared shocked and stoned. Patient 3's daughter notified, MD and supervisor made aware. Advised all CNAs to monitor both patients (2 and 3) for changes and Patient 3 for safety. A review of Patient 3's "Incident Report," dated 3/19/2024 at 9:10 a.m., indicated, Patient 3 was asked if there was any encounter with a man the night before, planned or unplanned encounter, Patient 3 claimed, "I don't recall of anything." During an interview on 4/2/2024 at 12:06 p.m., with the Director of Nursing (DON), the DON indicated, Patient 2 was seen touching Patient 3's breast, but Patient 3 is not able to recall. DON stated, "We did the monitoring for the behavior and then we made the decision if it's reportable, we investigate and talk to the patient and notify the MD and family." During an interview on 4/2/24 at 1:44 p.m., with the Social Services Director (SSD), the SSD indicated, Patient 2 did touch Patient 3's breast, but Patient 3 has no recollection. When asked if the incident was reported to authorities, the SSD stated, "I'm not sure if it was or not." During a concurrent interview and record review on 4/2/2024 at 2:20 p.m., with the DON, the facility's Policy and Procedure (P&P) titled, "Abuse Prevention and Prohibition Program," dated October 1, 2023, was reviewed. The P&P indicated, "IX. Special Considerations for Repotting Suspected Incidents of Criminal Sexual Abuse ... i. The Facility will treat allegations as criminal sexual abuse wherein the Facility determines that the resident does not have the decision-making capacity to consent to the sexual act ... C(i) The proper authorities and individuals are notified immediately or within two (2) hours, including but not limited to law enforcement, the Attending physician, the resident's representative, the state survey agency, and adult protective services ... "The DON stated, "We didn't report it because of the fact that when we investigated it, (Patient 3) was denying it." The DON further verbalized Patient 3 is not independent in decision making. The DON stated, "We did not report it. We should have reported it," and further verbalized, they did not follow their P&P. This facility failure is a violation of the Health and Safety Code (H&SC) 1418.91 (a)(b) which mandates facilities to report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.