Other·May 18, 2021

F610 Investigate/Prevent/Correct Alleged Violation §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Title 22 §72523. Patient Care Policies and Procedures a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/27/19 at 10:05 A.M., an unannounced visit was conducted at the facility to investigate a complaint alleging sexual abuse and to investigate a Facility Reported Incident (FRI) alleging rough handling during care, which occurred on 6/19/19 while personal care was being performed. Based on the investigation, the facility failed to ensure a resident was protected from potential sexual abuse when: The Facility failed to follow the facility's Abuse Investigation and Reporting policy by not investigating and reporting an incident, referred to as rough handling, as sexual abuse when Resident 1 told staff that she felt that she had been sexually assaulted by certified nursing assistant (CNA) 6 when he allegedly inserted his fingers into her anus during a brief change and later became upset when observing CNA 6 in the facility after the incident. As a result of this failure, vulnerable residents were put at risk for abuse. Resident 1 was readmitted to the facility on 5/12/19, per the facility's Resident Face Sheet. Per the History and Physical, dated 5/14/19, Resident 1's diagnoses included metabolic encephalopathy (condition in which brain function is disturbed due to different diseases in the body), and mild dementia (memory loss). A review of Resident 1's MDS (minimum data set) assessment (an assessment tool) dated 6/5/19, indicated the resident scored 14 on the BIMS (a score of 13-15 indicated the resident was cognitively intact and able to make decisions on her own). The MDS further indicated that Resident 1 required extensive assistance from one staff member for toileting activities. On 6/27/19 at 10:05 A.M., an interview was conducted with the facility's administrator (ADM). The ADM stated she investigated an incident of alleged rough handling that took place during Resident 1's incontinence (inability to control bowel or bladder) care and brief change. The ADM stated the allegation was against CNA 6 working on the night shift on 6/19/19. The ADM stated during her interview with Resident 1 on the day of the alleged incident, the resident did not allude to the incident being sexual. A review of CNA 6's undated statement indicated, "...When I removed her brief I saw that she had redness around her anus, and in between her butt cheeks. When I started to clean her [Resident 1] she said I was being too rough. I said that I was sorry for the discomfort, and I would try to be gentler... I said she had a BM [bowel movement] so I have to get her clean. She asked to put cream on her after I was done, and [I] obliged her request...." On 6/27/19 at 11:50 A.M., an interview was conducted with a Licensed Nurse (LN2) who worked the day shift 6/19/19. LN 2 stated that Resident 1 came to her on 6/19/19 between 8:00 A.M. and 10:00 A.M. and told her she did not like the way CNA 6 handled her during the cleaning of an incontinence episode. LN 2 stated that Resident 1 asked her to speak to the Director of Nursing (DON) about it. LN 2 stated Resident 1 told her CNA 6 had inserted his fingers into her anus. LN 2 stated Resident 1 referred to what CNA 6 had done as something that started with an "s," a word she was not familiar with. LN 2 stated she did not report Resident 1's allegation against CNA 6 to the DON because she assumed the LN and Charge Nurse taking care of Resident 1 would have reported it. LN 2 stated she should have reported it. On 6/27/19 at 2:35 P.M., an interview was conducted with Resident 1, who stated it was difficult to recall the exact date, but on one occasion, CNA 6 had changed her soiled brief and was "real rough." Resident 1 stated CNA 6 had "big fingers" that he put into her anus. Resident 1 stated "it hurt really bad" and she had asked him to stop. Resident 1 stated CNA 6 did not stop, and he continued by telling her he had to get her clean. Resident 1 stated it felt like the incident had gone on for five minutes. Resident 1 stated, "I just went numb and was kinda (kind of) in a sort of shock and just shut down." Resident 1 stated the actions of CNA 6 "made her feel violated." Resident 1 further stated CNA 6 put an ointment on her perineal area and that he "just focused on my anus" while applying the ointment. Resident 1 stated she saw CNA 6 in the facility again a few days after the incident, and "I couldn't believe it." Resident 1 further stated she had told LN 2 and CNA 2, the morning of the alleged incident, that CNA 6 had sodomized (anal penetration) her. Resident 1 stated she did not want something like this to happen to someone else. When asked how she felt about her safety at this facility, Resident 1 stated she did feel safe in the facility and had since the beginning of her stay. On 6/27/19 at 3:50 P.M., an interview was conducted with the facility's ADM. The ADM stated it was now clear there was a sexual aspect to Resident 1's allegation, and that she would re-suspend CNA 6 and notify the police. The ADM stated when Resident 1 asked CNA 6 to stop providing care he should have stopped. The ADM stated CNA 6 was reeducated on the need to stop providing care immediately when requested by the Resident. The ADM stated the investigation would have been handled differently had she been aware of the sexual allegation. The ADM acknowledged the investigation into Resident 1's allegation should have been more thorough before allowing CNA 6 to return to duty (on 6/23/19). The ADM stated, "We could have done better." A review of facility documents titled One on One Inservice, signed by CNA 6 on 6/21/19, indicated, " ...Employee will understand and adhere to rough handling policy ...." On 6/28/19 at 8:20 A.M., an interview was conducted with CNA 2. CNA 2 stated she took care of Resident 1 during the day shift on 6/19/19. CNA 2 stated she went in to see Resident 1 at the start of her shift (around 7:00 A.M.) and noticed the resident seemed "different" and was upset. CNA 2 stated Resident 1 told her she had a bad night last night. CNA 2 stated Resident 1 told her CNA 6 had been "really rough" during a brief change and had been "digging in there." CNA 2 stated Resident 1 told her she felt "sodomized" by CNA 6. CNA 2 stated she did not know what sodomized meant and had to "google it" when she got home. CNA 2 stated that when a resident made an allegation of being sodomized, it would be considered sexual abuse. CNA 2 stated she should have come forward and told the ADM about Resident 1's sexual abuse allegation. CNA 2 stated she did not tell the ADM because she had assumed everyone was aware of the sexual nature of the allegation. On 6/28/19 at 10:30 A.M., a joint interview and record review was conducted with the Social Services Assistant (SSA). The SSA stated the SSA's role included interviewing residents who made allegations against a staff member or complained about the way they were treated. The SSA stated she tried to interview Resident 1 on 6/20/19, but the resident did not want to discuss what had allegedly happened to her. The SSA reviewed Resident 1's clinical record and stated that she had not documented her attempt to interview Resident 1, or the resident's refusal of that interview. The SSA stated that it was her job to interview the residents who were cared for by CNA 6 to verify if there were any further complaints related to the care he provided. The SSA stated she did not verify which residents CNA 6 had actually provided care for, but that she should have. The SSA stated that Resident 1's allegation should have been looked into more thoroughly. On 6/28/19 at 11:15 A.M., an interview was conducted with CNA 6. CNA 6 stated he took care of Resident 1 on 6/19/19 and had changed her brief around 6:00 A.M. CNA 6 stated that Resident 1 told him he was too rough, but never asked him to stop. CNA 6 stated that Resident 1 asked him to put A & D ointment on her. CNA 6 stated that LN 1 gave him a cup with A & D in it that was mixed with a barrier cream and he applied it to Resident 1. CNA 6 stated when he applied the cream, he "avoided the vagina and anus entirely." On 6/28/19 at 12:10 P.M., an interview was conducted with the Assistant Administrator (AA). The AA stated CNA 2 and LN 2 should have reported Resident 1's allegation of sexual abuse to the AA or ADM. The AA stated an allegation of sodomy was different from rough handling. The AA further stated that when staff did not report Resident 1's sexual abuse allegation, it contributed to the facility's inaccurate reporting of the incident to the State Agency. The AA stated the facility should have notified the State Agency of Resident 1's sexual abuse allegation. The AA further stated the facility's investigation of Resident 1's allegation against CNA 6 had not been thoroughly investigated, and it should have been. The AA stated that not all staff relevant to the alleged incident had been interviewed before CNA 6 had been cleared to return to work and provide patient care. The AA stated the SSA should have verified CNA 6's assignments when checking for, and interviewing, potentially affected residents. The AA stated when Resident 1 declined to be interviewed by the SSA, the social services director should have been notified. The AA stated that the manner in which Resident 1 was treated would have been different had the facility been aware of the sexual allegation. The AA stated had the facility been aware, Resident 1 would have been sent to the emergency room for a sexual assault exam and the police would have been called. The AA further stated the facility had not sent a report of their investigation findings to the State Survey Agency within five working days, and that the notification should have been made timely. On 7/16/19 at 5:25 A.M., an interview was conducted with CNA 1. CNA 1 stated she had not worked on the night of the alleged incident (6/19/19). CNA 1 stated she returned to work a couple of days later, and Resident 1 told her of the alleged incident with CNA 6. CNA 1 stated Resident 1 told her she had felt "raped" by CNA 6, and that CNA 6 had put his fingers in her anus. CNA 1 stated the first time she was interviewed by the facility related to Resident 1's allegation was approximately two weeks after the incident. CNA 1 further stated she was working the night (6/23/19) that CNA 6 was cleared to return to work after being suspended by the facility. CNA 1 stated she told CNA 6 that he could not be in Resident 1's section because the resident said he had sodomized her. CNA 1 stated, "I got in report he [CNA 6] couldn't work with her [Resident 1] and he shouldn't be in the section, but he was." CNA 1 stated Resident 1 was visibly upset when she saw CNA 6 in her residential section. CNA 1 stated LN 1, who was the night Charge Nurse, had not been aware of Resident 1's allegation, or CNA 6's suspension or clearance to return to work. On 7/16/19 at 6:15 A.M., an interview was conducted with LN 1. LN 1 stated she had worked on the night of the alleged incident (6/19/19) and had been the nurse in charge. LN 1 stated the facility had not interviewed her related to Resident 1's allegation against CNA 6. LN 1 stated when CNA 6 had been cleared and returned to work (6/23/19) she as the nurse in charge, learned about the incident from a CNA and not management. LN 1 stated, "I was blindsided." On 7/16/19 at 7:25 A.M., an interview was conducted with Resident 1. Resident 1 stated the facility did not notify her of the outcome of their investigation into her allegation against CNA 6. Resident 1 stated she was not told what happened, or if CNA 6 was allowed to continue to work at the facility and provide care to residents. On 7/16/19 at 9:00 A.M., an interview was conducted with the DON. The DON stated when Resident 1 told LN 2 and CNA 2 about feeling sodomized by a CNA, both staff should have reported the allegation to the ADM or DON. The DON stated all staff to whom the residents report an allegation of abuse to were required to report it to the ADM. The DON stated all staff were considered mandated reporters and were required to report all allegations of abuse. The DON stated there were mandated reporters in this case who did not report Resident 1's sexual abuse allegation. The DON stated this should not have happened. The DON further stated, "I think we could have done a more thorough investigation." The DON stated that the staff on the night shift who worked with CNA 6, and those who were at work on 6/19/19, should have been interviewed related to the alleged incident involving CNA 6 and Resident 1. The DON stated all staff pertinent to Resident 1's allegation should have been interviewed before CNA 6 was cleared and allowed to return to work to provide patient care. The DON stated had the facility been aware of Resident 1's allegation of being sodomized sooner, the facility would have sent her to the emergency room for an evaluation, and the police would have been called, in order to provide protection to the resident. The DON further stated the facility had not provided the results of their investigation of Resident 1's allegation to the State Survey Agency within five working days. The DON stated that the notification should have been sent timely. Per the facility's policy titled Abuse Investigation and Reporting, revised December 2016, " ...All reports of resident abuse ... shall be promptly reported ... and thoroughly investigated by facility management. Findings of abuse investigations will also be reported ... 6. The Administrator will inform the resident ... of the status of the investigation and measures taken to protect the safety and privacy of the resident ... 1. The individual conducting the investigation will, as a minimum: g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; j. Review all events leading up to the alleged incident ... 6. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident .