Other·May 24, 2022

§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; The facility failed to protect one of two sampled patients (Patient 1) from inappropriate sexual behaviors when: *Patient 2 was found in Patient 1's room on 3/1/22, lying on top of Patient 1. Patient 2 had a known history of inappropriate sexual behaviors such as exposing his private parts in common areas, masturbating in front of other patients, and wandering into female patient's rooms. Patient 1 did not have capacity to make decisions or give informed consent. The facility failed to monitor and supervise Patient 2's inappropriate sexual behaviors. This failure had the potential to cause harm to Patient 2's psychosocial well-being and placed other female patients at risk as potential victims of sexual abuse. Findings: Review of the facility's P&P titled Abuse Prevention Program revised August 2021 showed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from sexual abuse. As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. On 3/1/22, CDPH, L&C Program received a report from the facility that a charge nurse responded to a scream from a patient's room where Patient 1 resided. Upon entering the room, Patient 2 was seen on top of Patient 1. a. Health record review for Patient 1 was initiated on 3/7/22. Patient 1 was admitted to the facility on 7/28/21. Review of Patient 1's MDS dated 1/30/22, showed Patient 1 was severely cognitively impaired. Review of Patient 1's History and Physical examination dated 7/29/21, showed Patient 1 had fluctuating capacity to understand and make medical decisions. Review of Patient 1's care plan problem dated 3/1/22, showed Patient 1 had a potential for emotional distress due to recent episode of sexual aggression by a male patient. On 3/7/22 at 0835 hours, an interview was conducted with the Administrator. The Administrator stated Patient 2 was found on top of Patient 1. The Administrator added both patients were clothed at the time of the incident. The Administrator stated she notified the Police Department regarding the incident on 3/1/22, and Patient 2 was taken into police custody the same day. b. Closed health record review for Patient 2 was initiated on 3/7/22. Patient 2 was admitted to the facility on 9/16/21. Review of Patient 2's History and Physical examination dated 10/6/21, showed the patient had fluctuating capacity to understand and make medical decisions and was assessed to have agitation. Review of Patient 2's care plan problem dated 12/1/21, showed the facility noted an episode of Patient 2 touching his genitals in front of another patient. The care plan interventions included to provide privacy, remind Patient 2 inappropriate sexual behavior was inappropriate, refer to psychology, and redirect to other activities. Another care plan problem dated 12/16/21, showed the patient had tendency to remove his genitals in the presence of others. The care plan interventions included redirect Patient 2 and correct negative behavior, psychology referral as needed, contact family about taking the patient home, and staff to monitor closely when up in chair. Review of Patient 2's Behavior Note dated 12/1/21, showed Patient 2 was found sitting in front of another patient touching his genitals. Review of Patient 2's IDT Review note dated 12/6/21, showed the IDT had met for an incident of the patient touching his genitals next to another patient. The recommendations were to redirect the patient, assist the patient to room, provide privacy, and provide psychiatric and psychological consults. Review of Patient 2's two IDT Review notes dated 12/15/21 at 1635 and 1659 hours, showed the IDT had met with Patient 2 to discuss exposing himself in front of a female patient and the second incident where Patient 2 had a sexual encounter with a female patient. The recommendations were to make rounds on the patient every two hours, contact family for possible discharge, educate patient to report any incidents of a female patient making sexual advances towards him and patient understood he could not engage in the behavior again. Review of Patient 2's IDT Review dated 12/28/21, showed the IDT had met regarding Patient 2 exposing himself. The recommendations included to keep the patient in activities, group, supervised areas, or one on one with staff when propelling self through halls, and staff education of the recommendations. Review of Patient 2's Social Service Note dated 1/25/22, showed Patient 2 was observed entering another patient's room, going into the hub unattended, and was redirected by CNA to avoid being close to any female patients. Review of Patient 2's Social Service Note dated 2/23/22, showed the SSD conducted a follow-up care plan meeting in regard to Patient 2's inappropriate behavior. Patient 2 was able to state when he had the physical urge, the patient would go to the shower room or back to his room and pull the privacy curtain or go back to bed and cover himself with his blankets. Patient 2 was able to verbalize agreement with the plan of care. Review of Patient 2's Health Status Note dated 2/28/22, showed Patient 2 was noted to be wandering around and found in a female room. Review of Patient 2's Health Status Note dated 3/1/22, showed at 0645 hours, a female patient (Patient 1) was heard screaming. LVN 3 and CNA 2 attempted to open the door, but Patient 2's wheelchair blocked the door. Once the door was opened, Patient 2 was found on top of Patient 1. Patient 2 was observed wearing a night gown without undergarment, and Patient 1 was observed with her night gown, but her brief was partially torn on the left side. On 3/7/22 at 0922 hours, a telephone interview was conducted with the facility's LTC Ombudsman. The Ombudsman stated he had concerns with Patient 2's behavior because the patient had a known history of inappropriate sexual behaviors. On 3/7/22 at 1253 hours, an interview was conducted with the Activities Assistant. The Activities Assistant stated Patient 1 was unable to make needs known and required assistance with ADL care and was unable to get out of bed without assistance. The Activities Assistant stated Patient 2 was recently relocated to Station C from Station A because Patient 2 had previous inappropriate sexual incident. The Activities Assistant verified Patient 2 was still able to self-propel in his wheelchair around the facility. On 3/7/22 at 1437 hours, an interview was conducted with CNA 3. CNA 3 stated Patient 2 was previously in Station A but was moved to Station C. CNA 3 stated Patient 2 was alert and oriented and exhibited sexual behaviors such as exposing himself to other patients in the hallway. CNA 3 stated, "He knew what he was doing." CNA 3 stated Patient 1 was confused and required assistance with ADL care. On 3/7/22 at 1453 hours, an interview was conducted with Patient 1. When asked, Patient 1 stated she could not recall the incident between her and Patient 2. On 3/7/22 at 1443 hours, an interview was conducted with RNA 2. RNA 2 stated Patient 2 was alert and oriented and would "pull his pants down." RNA 2 stated, "Patient 2 knew what he was doing when he exposed himself." RNA 2 stated Patient 2 would propel in his wheelchair throughout the facility. On 3/7/22 at 1447 hours, an interview was conducted with Patient A. When asked if he was aware of anyone in the facility that exhibited inappropriate sexual behaviors, Patient A stated Patient 2 would "expose himself to the olde ladies." Patient A stated Patient 2, "knew what he was doing because he would only pick the ladies who were confused or seemed out of it." Patient A stated Patient 2 did not conduct inappropriate sexual behaviors around him because Patient 2 knew "I was with it and not confused." Patient A stated he observed Patient 2 exposing himself in the hallways and common areas. On 4/5/22 at 1037 hours, a telephone interview was conducted with CNA 2. CNA 2 stated his normal shift schedule was from 2300 hours to 0700 hours. CNA 2 stated LVN 3 and he responded to a female screaming loudly close to shift change. CNA 2 stated LVN 3 and he entered the room and found Patient 2 on top of Patient 1. CNA 2 added Patient 2 was wearing clothes, however, was not wearing underwear on. On 4/7/22, at 1400 hours, a telephone interview was conducted with LVN 3. LVN 3 stated she worked on 3/1/22, the day the incident occurred between Patients 1 and 2. LVN 3 stated she heard someone screaming around 0645 hours. LVN 3 stated the screaming was coming from a female patient's room. LVN 3 stated CNA 2 and her responded to the screaming, but when they tried to open the door, a wheelchair was blocking the entry way. LVN 3 stated when the door finally opened, Patient 2 was observed on top of Patient 1. LVN 3 stated they immediately separated the patients. LVN 3 stated Patient 2 was alert, oriented, and able to make a conversation. LVN 3 stated Patient 2 was able to propel himself in the wheelchair around the facility. LVN 3 stated she was not made aware Patient 2 was being monitored for inappropriate sexual behaviors. LVN 3 stated she did not receive endorsement or report from the previous shift Patient 2 was to be monitored. LVN 3 stated she did not observe Patient 2 propelling in the hallway and entering Patient 1's room prior to the incident. On 4/13/22 at 1620 hours, a telephone interview was conducted with the SSD. The SSD stated Patient 2 was alert, oriented, and able to make needs known. The SSD stated every time she spoke with Patient 2, he was reminded to "keep to himself when he has sexual urges and needs." The SSD stated his sexual behaviors were reported by nursing and he exhibited behaviors of exposing himself to female patients and wandering in female patient rooms. The SSD stated Patient 2 was able to wheel himself around the facility. Patient 2 verbalized understanding each time we intervened and reeducated him. The SSD stated incident between Patient 2 and Patient 1 occurred on the night shift between the hours of 2300-0700 hours. The SSD stated nursing staff were responsible to monitor Patient 2's behaviors and whereabouts because Activities and Social Services were not there during those hours. On 4/14/22 at 0837 hour, an interview was conducted with the DSD. The DSD stated during huddle (brief daily meeting to discuss patient care) Charge Nurses would inform staff which Patient s needed monitoring for behaviors. The DSD stated for patients who are closely monitored for specific behaviors, licensed nurses would endorse and discuss behavior monitoring during end of shift report. This violation had a direct or immediate relationship to the health, safety, or security of the client.