Other·May 24, 2021

F 607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95 On 1/13/20, a Facility Reported Incident was reported to the California Department of Public Health (CDPH), involving an alleged staff to resident sexual abuse and an unannounced visit was made on the same day at 2:02 P.M. The facility failed to protect Resident 1 from sexual abuse when a Certified Nursing Assistant (CNA 5) entered Resident 1’s room and sexually abused the resident. As a result of the sexual abuse, Resident 1 was transferred to a General Acute Care Hospital (GACH), where a sexual assault exam was performed. The exam showed signs of vaginal injury, pain and bleeding. Following the sexual abuse, Resident 1 experienced nightmares and had difficulty sleeping, requiring the nightly administration of Prazosin (a medication that relieves nightmares) and Restoril (a medication that helps sleep). The facility failed to: 1. Develop and implement a comprehensive policy for screening potential employees for abuse by contacting the previous employers and asking if CNA 5 was rehireable. The Director of Staff Development (DSD) stated it was not the facility’s standard of practice, and previous employment verification was only conducted when the Director of Nursing (DON) specifically asked for it to be completed. 2. Prevent Resident 1 from sexual abuse by CNA 5 by failing to implement an abuse prevention policy and monitor inappropriate behavior of staff towards residents. As a result of these failures, the facility was unaware that CNA 5’s previous employers had terminated his employment and listed him as ineligible for rehire. Per the facility’s Admission Record, Resident 1, a 61-year-old female, was admitted to the facility on 12/4/19, for wound care and physical therapy following hospital debridement (the removal of damaged tissue) of the left lower extremity due to an infection. On 1/13/20, Resident 1’s clinical record was reviewed. Resident 1’s most recent Minimum Data Set (MDS-an assessment tool), dated 12/11/19, indicated a Brief Interview for Mental Status (BIMS-a cognitive assessment) score of 15 (score of 13-15 indicates full understanding, reasoning and thinking ability). Resident 1’s Functional Status indicated she was able to ambulate (walk) on her own, without the use of any medical devices. On 1/13/20 at 2:35 P.M., a concurrent observation and interview with Resident 1 was conducted. Resident 1 was observed as tearful and periodically stopped to cry while being interviewed. Resident 1 stated on the afternoon of 1/10/20, she was outside on the smoking patio when CNA 5 approached her and started to rub her neck. Resident 1 commented, “That feels good” and CNA 5 stated he knew something that would make her feel even better. Resident 1 stated she did not know what CNA 5 meant by that comment and she did not ask him. Resident 1 stated sometime after 8:00 P.M., she was lying on her bed, with the door closed, watching TV with her privacy curtain partially pulled. Resident 1 stated CNA 5 entered her room unannounced and appeared inside her privacy curtain without saying anything. Resident 1 stated she had not activated her call light and she did not know why CNA 5 was in her room. Resident 1 stated CNA 5 had never cared for her before and she thought maybe CNA 5 was in her room to empty the trash. Resident 1 stated CNA 5 suddenly pulled down her personal throw blanket. Resident 1 stated she was shocked and confused and asked him what he was doing. Resident 1 stated CNA 5 told her he was going to make her feel good, and he attempted to kiss her, using his tongue. Resident 1 stated she pulled away from CNA 5’s face and he covered her mouth with his right hand. Resident 1 stated CNA 5 pulled down her underwear and began jamming his fingers in her vaginal area, while keeping his right hand over her mouth. Resident 1 stated she was able to pull her mouth away from CNA 5’s hand and she told him to stop, but the CNA covered her mouth again. CNA 5 told Resident 1 not to tell anyone, because no one would believe her. Resident 1 stated someone knocked on the door, and CNA 5 stopped what he was doing, and pulled her blanket back up over her body. CNA 5 left the room quickly without saying anything. Resident 1 stated she heard a female say something and then CNA 6, who was her assigned CNA, appeared inside Resident 1’s privacy curtain. CNA 6 asked Resident 1 if she wanted a sandwich. Resident 1 stated CNA 6 saw she was crying. CNA 6 asked Resident 1 several times if she was okay. Resident 1 stated she was so shocked and speechless that she did not say anything. Resident 1 stated CNA 6 left the room, saying she would come back later to check on her. Resident 1 stated she called the police from her room after CNA 6 left. Resident 1 stated she was still in bed, waiting for the police to arrive when she heard someone enter the room without knocking or saying anything. Resident 1 stated CNA 5 returned to the side of her bed nearest the window. CNA 5 told Resident 1, “You’re going to have an orgasm and you’re going to thank me.” Resident 1 stated CNA 5 covered her mouth again, pulled down her blanket, and yanked on her underwear. Resident 1 stated she felt CNA 5 penetrate her vagina with his fingers and it hurt. Resident 1 stated CNA 5 stopped jamming his fingers into her and then he asked her if she had an orgasm. Resident 1 stated she nodded yes, because she just wanted him to leave. Resident 1 stated before CNA 5 left, he said, “Now you feel good, huh. Remember no one will believe you.” Resident 1 stated that the police arrived and took her to the general acute care hospital (GACH) for an examination. Resident 1 stated she started having vaginal bleeding and pain on the night of the abuse that continued at the time of the interview. Resident 1 stated the first time CNA 5 was in her room it was for about three minutes and the second time it was for about two minutes. Resident 1’s room contained two single beds and one bathroom. Resident 1’s assigned bed was the farthest from the entrance door, next to a window. Resident 2, Resident 1’s roommate, was assigned the bed closest to the door entering the room. Resident 1 believed her roommate was asleep and never woke up during the abuse. On 1/13/20, CNA 5’s employee file was reviewed. CNA 5 was hired on 9/20/19. CNA 5 listed three previous skilled nursing facilities (SNFs) where he was employed as a CNA between 2017 and 2019. The file contained no documented evidence that the facility contacted CNA 5’s previous employers for employment verification. On 1/14/20 at 1:54 P.M., an interview was conducted with CNA 6. CNA 6 stated she and CNA 5 worked double shifts on 1/10/20, starting in the morning through the P.M. shift, due to a CNA shortage that day. CNA 6 stated for the P.M., shift she was assigned to Resident 1. CNA 6 stated on 1/10/20, sometime after 8:00 P.M., she knocked on Resident 1’s door, to offer her and her roommate an evening snack. CNA 6 stated Resident 1’s roommate was sleeping. CNA 6 stated she saw CNA 5 come out from behind Resident 1’s privacy curtain and he left the room without saying anything. CNA 6 thought maybe CNA 5 had been in the room to answer a call light and she did not think anything of it. CNA 6 stated when she asked Resident 1 if she wanted a sandwich, Resident 1 had a strange look on her face, which she had never seen before. CNA 6 stated Resident 1 grabbed her forearm and stared at her strangely, without saying anything. CNA 6 stated she asked Resident 1 at least four times if she was all right, and the resident shook her head no and then nodded yes. CNA 6 stated she was concerned but confused with what was going on with the resident, so she told Resident 1 she would come back later to check on her. CNA 6 stated she left the room, closing the door. CNA 6 stated the police arrived unannounced about 30-40 minutes later. On 1/14/20 at 2:25 P.M., a telephone interview with CNA 5 was attempted. CNA 5 stated everything he had to say was in the written statement he gave the facility on the night he was suspended and that he had nothing additional to add. CNA 5’s handwritten statement, dated 1/10/20, stated at approximately 8:00 P.M., he went into Resident 1’s room to check on her. CNA 5 stated he told Resident 1 goodnight, gave her a hug, and left. On 1/21/20 at 12:12 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she was not employed by the facility at the time of CNA 5’s hiring. The DSD stated her role with prospective applicants was to verify their licensure and to order criminal background checks. The DSD stated after the criminal background checks and licensures were verified, the Business Office Employee/Payroll (BOE 2) contacted the applicant’s professional references and documented their responses on the facility’s Interviewers Comments document. The DSD stated she did not routinely verify previous employment and would only do so if the Director of Nursing (DON) specifically asked her to. The DSD stated if she was directed to call the former employer, she would inquire if the former employee was punctual, dependable, and eligible for re-hire. The DSD stated she would document the response and provide this information to the DON, who would make the ultimate decision for hiring. BOE 2 was interviewed on 1/21/20 at 12:20 P.M. BOE 2 stated she was responsible for contacting professional references only after the background check was completed by the DSD. On 1/21/20, CNA 5’s professional reference checks were reviewed. The facility’s Interviewers Comments form, dated 8/29/19, contained handwritten documentation that BOE 2 contacted two of the CNA's former co-workers. There was no documented evidence CNA 5’s three former employers listed were contacted for employment verification. An interview was conducted with the Administrator (ADM) on 1/21/20 at 12:32 P.M. The ADM stated he just started at the facility this week and was unsure of what the previous ADM hiring practices were. The ADM stated it was best practice to check and verify previous employment before hiring new staff. During a telephone interview, on 1/22/20 at 11:01 A.M., with one of CNA 5’s listed former employers, the Human Resource staff (HR 2) stated CNA 5 was listed as involuntary leave, (when the employer terminates the employee) and the employee was not eligible for rehire. During a telephone interview on 1/22/20 at 11:23 A.M., with another former employer of CNA 5, HR 3 stated CNA was listed as ineligible for rehire. A subsequent observation and interview was conducted with Resident 1 on 1/24/20 at 3:02 P.M. Resident 1 tearfully stated she was having nightmares and difficulty sleeping because of what CNA 5 did to her. Resident 1 stated she kept playing the incident over and over in her head and said, “I feel so dirty.” Resident 1 stated a psychiatrist recently prescribed her medications for recurring nightmares and to help her sleep. Resident 1’s physician’s progress note, dated 1/22/20, was reviewed. The Psychiatric Physician (MD 2) documented new medication orders, to include Prazosin (a medication for nightmares), and Restoril (a medication to assist with sleep), to be given every night. MD 2 also ordered weekly individual sessions with a psychologist (a mental health specialist). Resident 1’s Medication Administration Record (MAR), reviewed on 2/2/20, showed that from 1/23/20 through 2/2/20, Resident 1 received Prazosin and Restoril every night before bedtime. On 2/4/20 at 10:57 A.M., a telephone interview was conducted with the police detective (DET) assigned to investigate Resident 1’s allegation. The DET reviewed his notes and stated Resident 1 complained of vaginal pain before and after the sexual assault exam. According to the DET, the sexual assault nurse examination revealed Resident 1 had vaginal bleeding, along with redness and tenderness on the left interior (inside) vaginal wall. On 2/10/20 at 12:01 P.M., an interview was conducted with Resident 2. Resident 2 stated everyone kept asking her if she heard anything involving her roommate, Resident 1. Resident 2 stated she did not know anything because she was sleeping, and all she remembered was her roommate going to the hospital. On 2/11/20, Resident 1’s Forensic Medical Report, dated 1/10/20, was reviewed. The Sexual Assault Nurse Examiner (SANE) documented Resident 1’s external (outside) genital exam included redness, a bruise, and an abrasion. Resident 1’s internal (inside) vaginal exam included redness and bruising to the vaginal walls. On 4/7/21 at 4:41 P.M., a subsequent interview was conducted with DET. DET stated CNA 5’s DNA (deoxyribonucleic acid-the hereditary material in humans) was collected from Resident 1 during the forensic sexual assault exam. DET stated CNA 5’s DNA was found on Resident 1’s mouth, breast, and a small amount in the vagina area. According to the facility’s policy, titled Abuse Prevention Program, dated December 2016, “As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff…. 2. Conduct employee background checks….” According to the facility’s Standard Operating Procedures, Hiring Process, undated, “…Pre-Screening: Run a Criminal background check, … Verify certificate or license through agency site, Contact two professional references…” The procedure guidelines did not give direction for staff to verify past employment. The facility had no policy that specifically referred to contacting previous employers for verification of employment. The failure of the facility to develop a comprehensive policy for screening potential employees for abuse lead to Resident 1 to have been sexually abused. This abuse resulted in Resident 1 to experience pain and psychosocial distress. The above violation presented either imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result.