Other·May 9, 2022

C4425 T22 DIV5 CH3 ART5-72527(a)(10) Patient Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. The facility failed to provide a safe environment and protect one of three residents (Resident 1) from sexual abuse when the Central Supply Manager (CSM) kissed Resident 1's cheek and placed his hand on her leg without her consent. This failure resulted in an unconsented sexual abuse by CSM to Resident 1 who felt angry, helpless, fearful, anxious, and disrespected. An onsite visit was conducted on 2/24/2020 to investigate the incident. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on 6/5/2018. Resident 1 had Multiple Sclerosis (MS) (MS is a potentially disabling disease of the brain and spinal cord central nervous system) and she was not able to move her upper and lower extremities. Resident 1 required total assist in her activities of daily living. During an interview on 2/4/2020 at 4:55 p.m., the Administrator (ADM) stated Visitor F visited Resident 1 on 1/21/2020 at 3:30 p.m. After the visit with Resident 1, Visitor F reported to Social Service Director (SSD) that CSM kissed Resident 1 in her cheek without consent. The ADM stated after she learned about the complaint by Visitor F, she immediately placed CSM on work suspension for 3 days. ADM stated, CSM was given a sexual abuse training when he returned to work. ADM stated, CSM was given an instruction to never bring mail and packages personally to Resident 1 and not to enter the room of Resident 1. ADM and Social Service Director (SSD) stated that they met with CSM to discuss boundaries to residents. ADM stated, CSM returned to work on 1/24/2020. During an interview on 2/4/2020 at 5:40 p.m., Resident 1 was in her room laying in her bed. Resident 1 was alert and oriented to time, place, and people. Resident 1 had multiple electronic gadgets on her bedside table. Resident 1 demonstrated that she needed to have a pointer that she put in her mouth so she could point to the electronic pad to communicate her needs. Resident 1 stated, on 1/21/2020, CSM walked into her room and suddenly kissed her cheek without permission and touched her leg. Resident 1 stated Visitor F was in her room visiting and witnessed CSM kissed her cheek. Resident 1 stated she did not have any contact phone number for Visitor F. Resident 1 stated CSM did not ask her if he could kiss her. Resident 1 stated she did not give CSM consent to kiss her. Resident 1 stated she felt scared, surprised, upset, and felt taken advantaged. Resident 1 stated she was worried that CSM would enter her room and do it again. Resident 1 stated she felt helpless due to her immobility. Resident 1 stated that in the past, CSM told her in multiple occasions that he would like to flirt with her. Resident 1 stated she had not seen CSM after the kissing incident because she was hospitalized on 1/23/2020 and returned to the facility on January 28, 2020. Resident 1 stated that on January 28, 2020, when the Emergency Technician (EMT) brought her to her room as she lay in the gurney, she noticed that CSM was in her room talking to her roommate. Resident 1 stated CSM did not look at her and he left her room immediately. During an interview on 2/4/2020 at 6:15 p.m., ADM stated she was not aware of CSM being in Resident 1's room on 1/28/2020 when Resident 1 returned from the hospital. ADM stated she had instructed CSM to do not enter the room of Resident 1. During an interview on 2/5/2020 at 8:05 a.m., CSM stated he kissed Resident 1 on the cheek, like a peck. CSM stated he entered her room and leaned towards and kissed her. CSM stated he did not ask Resident 1 for a permission to kiss her. CSM stated he kissed her because he thought that they were developing a relationship. CSM further described the relationship as a good friendly relationship. CSM stated he was friendly to other residents and when happy, he would like to kiss them. When asked how many residents in this facility he had kissed, CSM stated he only kissed Resident 1. CSM stated he would bring her mails and open packages for Resident 1. CSM stated Resident 1 was appreciative when he helped. CSM stated he felt that Resident 1 was nice to him, and they were developing a relationship. CSM stated he would hold her hands. CSM stated it was not his job to deliver mails and packages, but he would be happy to bring it to Resident 1. CSM stated the office staff asked him to bring the mail and package to Resident 1. CSM stated when he returned to work after the suspension, he watched the video and sexual abuse training given by the SSD. CSM stated the ADM and SSD told him not to enter the room of Resident 1. CSM stated that on January 28, 2020, he entered the room of Resident 1 because Resident 7 (roommate of Resident 1) was calling for help. CSM stated he never told Resident 1 that he wanted to flirt with her. During a review of CSM personnel file, revealed that he first started working as a Cook for the facility. In July 2019, CSM was promoted to Central Supply Department. His job description was to check the serial number of oxygen equipment and change bed mattresses in resident's room. CSM received sexual abuse training, Elderly abuse training and counseling regarding boundary on 1/23/2020. During a record review of the Policy and Procedure titled "Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable suspicion of a crime in the facility Policy and Procedure", revised 3/2018 indicated, on page 4, under Protection revealed, "The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation ..." On page 2, B) Training revealed, 1) Orientation program upon hire will include review of facility's policy on Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation; Identifying what constitutes abuse... 2) All employees and volunteers will be oriented to their role in abuse prevention as mandated reporters and that abuse will not be tolerated in the facility. 3) Yearly and/or as necessary in services will be provided for review of facility's Policy on Abuse Prevention, Mandated Reporting, and individual's obligation to comply with reporting requirements. Therefore, the facility failed to provide a safe environment and protect one of three residents (Resident 1) from sexual abuse when the Central Supply Manager (CSM) kissed Resident 1's cheek and placed his hand on her leg without her consent. This failure resulted in an unconsented sexual abuse by CSM to Resident 1 who felt angry, helpless, fearful, anxious, and disrespected. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.