Health inspection·January 17, 2023

Health and Safety Code Section 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. On 11/4/22 at 10:35 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of resident sexual abuse by a facility staff member. The anonymous complaint received by the Department indicated, on 11/2/22, at 6:45 a.m., Resident 1 informed a staff member that a “[certified nursing assistant name] assisted her to the restroom and did something to her while in the restroom that is now causing her vaginal area to hurt.” Resident 1’s allegation was reported to a supervising Licensed Nurse. Record review indicated Resident 1 was a 66-year-old female, admitted to the facility on 4/1/21, with diagnoses including psychiatric disorders, need for assistance with personal care, and difficulty walking. The facility’s “Abuse Prevention Program,” dated 11/2020 indicated, “All allegations of abuse, mistreatment, and neglect are to be reported to State Licensing Agency [Department] immediately or within twenty-four hours… The facility must follow-up in writing.” During a review of the clinical record for Resident 1, the “Psychology Note and Treatment Plan,” dated 10/31/22, indicated Resident 1 was a good communicator with an excellent memory. During an interview with Resident 1, on 11/4/22 at 11:49 a.m., she stated “[Certified Nursing Assistant name] touched me.” Resident 1 further stated, “I told him I would like to get to know him. I stood in the bathroom and let him play with me. I touched him a little bit. I don’t want him to get in trouble.” Resident 1 demonstrated how CNA touched her by pointing to her vaginal area. She then stated she didn’t tell any staff until she had an “itch,” and thought it was a “STD” (sexually transmitted disease). During a review of the clinical record for Resident 1, the Progress Note dated 11/2/22, at 4:52 p.m., indicated, “AT 0730 AM today, resident commented to the charge nurse that a male staff while providing peri care touched her in her private area…According the staff member being accused of inappropriate touching.” During an interview with the Assistant Administrator (AADM) on 11/04/22 at 12:54 p.m., he stated he investigated Resident 1’s allegation of inappropriate touching as follows: - On 11/02/22 at 7:53 a.m., he received a cell phone call from the Director of Nursing (DON) about Resident 1’s allegation - On 11/02/22 at about 8:30 a.m., he interviewed Resident 1 - On 11/02/22 DON and the Director of Staff Development (DSD) interviewed Resident 1 - On 11/02/22, at 9:28 a.m., he reported their findings to the Administrator (ADM). The ADM instructed him to interview [licensed nurse name] (LN2) - On 11/02/22, “After lunch,” he interviewed LN2 - On 11/02/22, DSD interviewed the CNA accused of inappropriate touching (CNA1) The AADM added he did not report the allegation immediately to the Department. During an interview on 11/4/22 at 2:59 p.m., with Resident 1 and ADM, Resident 1 explained to ADM how CNA1 was rubbing her vagina. Resident 1 put her hand to her vaginal area and imitated rubbing in circles. ADM asked Resident 1, “Did you and [CNA1 name] have sex?” Resident 1 replied there were times when she touched [CNA1’s name] private parts and [CNA1 name] touched her private parts when it wasn’t for the purpose of cleaning her. During an interview on 11/4/22 at 3:11 p.m., with ADM, he stated, “I need to suspend [AADM name] for neglect to report the abuse.” This facility’s 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.