§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;
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Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to prevent resident to resident sexual abuse and ensure that a resident was free from sexual abuse for one of 17 sampled residents.
(Resident 12)
Finding include:
Clinical record review revealed that Resident 12 was admitted to the facility on December 10, 2015, with diagnoses that included Alzheimer's disease, anxiety disorder, depression, psychotic disorder, and mood disorder. Review of Resident 12's Minimum Data Set (MDS) assessment completed November 4, 2019, revealed that the resident's cognition was severely impaired.
Clinical record review revealed that Resident 53 was admitted to the facility on March 6, 2018, with diagnoses that included dementia, major depressive disorder, and adjustment disorder with depressed mood. Review of Resident 53's MDS assessment completed January 15, 2020, revealed that his cognition was intact, and that he was able to understand others.
A review of Resident 53's care plan, developed on February 4, 2019, included a problem area for behavior related to Resident 53's history of touching other female residents. An intervention included that staff check the resident every 15 minutes to prevent him from having contact with female residents.
On January 20, 2020, Resident 53 was evaluated by a psychologist who documentated that the resident had a preoccupation with sexual thoughts directed towards other female residents, and that he lacked the ability to control his actions. The psychologist recommended staff closely monitor Resident 53 when in close contact with female residents. On January 25, 2020, at 7:30 p.m., staff (CNA 1) witnessed Resident 53 "putting his hand down Resident 12's blouse and rubbing."
In an interview on February 12, 2020, at 10:05 a.m., the Director of Nursing confirmed that there was no documentation to support that the resident was consistently being monitored for behaviors and that the facility failed to ensure that Resident 12 was free from sexual abuse.
28 Pa. Code 201.18 (b)(1) Management.
28 Pa. Code 211.12(d)(1) Nursing services.
| | Plan of Correction - To be completed: 03/23/2020
1. R 53 discharged from the facility; (R12 was offered emotional support and prevented from any sexual abuse)
2. Any residents identified as having/showing that exhibits behaviors of potential sexual abuse will be monitored by staff to assure that residents are free from abuse.
3. Education was provided by staff educator/designee for all staff on the importance of keeping all residents free from sexual abuse. abuse prevention. Residents will be informed during care conference of resident rights and abuse prohibition.
4. Audits will be done by DON/designee weekly x4, monthly x3, then quarterly or until compliance is achieved of residents exhibiting behaviors of potential sexual abuse to assure that all residents are free from abuse. Findings will be reviewed with QAPI committee monthly.
5. Date of compliance: - 3/23/20
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