§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 review of facility policies, clinical records, review of facility investigation and staff interviews, it was determined that the facility failed to implement adequate safeguards to protect cognitively impaired residents in a secured memory unit from sexual abuse, the facility failed to identify abuse as sexual and failed to assess current and past residents that may have been sexually abused, these failures resulted in sexual abuse on one Resident of 29 cognitively impaired residents (Resident R2). This failure placed 29 residents at risk of sexual assault and resulted in an Immediate Jeopardy situation.
Findings include:
Review of facility policy "Resident Protection from Abuse, Neglect or Exploitation" dated 11/1/21, indicated: Sexual abuse means non-consensual sexual contact of any type with a resident and includes sexual harassment, sexual coercion or sexual assault.
Review of CMS Guidelines Freedom from Abuse, Neglect, and Exploitation defines sexual abuse as:
"Sexual abuse" is non-consensual sexual contact of any type with a resident, as defined at 42 CFR Sexual abuse includes, but is not limited to:
o Unwanted intimate touching of any kind especially of breasts or perineal area;
o All types of sexual assault or battery, such as rape, sodomy, and coerced nudity;
o Forced observation of masturbation and/or pornography; and
o Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident.
A review of information provided to the department indicated the following:
Facility staff was notified on 4/24/22, by Resident R3 that there was a male resident with no pants on and his privates out.
Nurse Aide (NA) Employee E2 entered room and observed Resident R2 on the floor with no pants or brief on and shirt unbuttoned, legs in the air with ankles being held by Resident R1 (who was naked below the waist with penis exposed) who was pulling at Resident R2. Resident R2 was scooting across floor attempting to get to roommates bed near window (other side of room away from Resident R1).
NA Employee E2 and E30 asked Resident R1 what they were doing the following took place:
Resident R1 (who was naked below the waist with penis exposed) was nervous and hurried over to the bed and started to pull on a pull up (depends/brief) upon Nurse Aides entering room. Room was covered in white fluff cotton that looked like it snowed, which were from Resident R2's brief.
NA Employee E2 and E30 stood Resident R2 up and Resident R2 hugged the Nurse Aide and they walked him/her out of the room.
The incident/event type was listed as "physical" abuse.
Resident R2 was admitted to the facility on 4/18/17, with Alzheimer ' s disease which remains current as of the 4/14/22, Minimum Data Set (MDS - a brief periodic assessment of resident needs).
Review of Resident R2 ' s Minimum Data Set dated 4/14/22, indicated that she has no BIMS (brief interview for mental status) because her cognition is severally impaired.
MDS also indicated that her Activity of Daily living (ADL's - residents ability to complete daily living skills) for dressing was a "3/3" which equals an extensive assistance and a two person assist.
Review of clinical progress notes "health status notes" dated 4/24/22, 10:32 p.m. , indicated "Staff reported another resident reported to them there is a man down the hall without any pants on. As staff going to said room observed male resident dragging this resident on the floor without pants on brief shredded on floor bed alarm sounded male resident stated to staff he unbuttoned her shirt. Staff got resident off the floor 2 small scratches noted to resident."
Review of clinical progress notes "Weekly Skin & Wound Note" dated 04/25/22, at 1:32 a.m. indicated "Resident has a wound on the right abdomen. Resident has a wound on the left abdomen. RLQ/Hip area. 04/24/22, is when the wound was found acquired in - house. The current measurements are Length 4.5 cm intact. The peri wound area is normal skin tone. There is no drainage in the wound. Abrasion Left side in middle, 04/24/22, is when the wound was found acquired in - house. The current measurements are Length: 8 cm intact. The peri- wound area is normal skin tone.
Prior to 4/24/22, Resident R2 had no documented wounds on the right and left abdomen.
During interviews with facility employees Nurse Aide (NA) Employee E2 on 5/6/22, at 9:23 a.m. Licensed Practical Nurse (LPN) Employee E3 on 5/6/22, at 5:40 p.m., and E30 on 5/7/22, at 7:23 a.m. the following was indicated :
NA Nurse Aide (NA) Employee E2 and E30 and Licensed Practical Nurse (LPN) Employee E3 identified the above incident as a sexual abuse.
NA Employee E2 and E30 and LPN Employee E3 identified that Resident R2 (alleged victim) was trying to scoot away from Resident R1(alleged perpetrator) and create further distance from Resident R1.
NA Employee E2 and E30 and LPN Employee E3 indicated Resident R1 (alleged perpetrator) was acting nervous after the incident, nursing staff indicated that they did not receive training about abuse after the above incident nor did they complete assessments on other residents. During the same interviews with NA Employee E2, E30 and LPN Employee E3 all indicated that they reported the incident to the Registered Nurse on duty (RN Employee E26) and completed witness statements after the incident.
NA Employee E2 and E30 and LPN Employee E3 indicated that prior to the incident Resident R2 needs assistance with taking off clothing and does not like to be touched or changed.
A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment
A review of the prescribing information for ropinirole, a medication used to treat symptoms of Parkinson's disease, (progressive nervous system disorder that affects movement) revised 2/15/22, indicated that ropinirole is a dopamine agonist (medications that work by imitating the actions of dopamine when levels are low) indicated that some people who take ropinirole have increase sexual urges.
Resident R1 was admitted to the facility initially on 1/13/15, and readmitted on 11/24/17.
Review of Minimum Data Set (MDs, periodic review of resident needs) dated 11/10/21, indicated diagnoses of Parkinson's disease, anxiety, depression and intellectual disabilities. Review of Section C: Cognitive Patterns, Questions C0500 "BIMS Summary Score" revealed Resident R1's score to be "5", indicating severe impairment.
Review of the clinical record indicated that on 4/20/22, an additional diagnosis of violent behavior was added to the diagnosis list.
Review of the physician order history indicated ropinirole ordered in varying doses from:
1/13/15-4/20/15
4/20/15-7/25/15
8/01/15-1/30/16
2/03/16-8/17/16
8/18/16-1/02/19
1/02/19-5/02/22
Review of Resident R1's plan of care for psychotropic medication use, originally initiated 1/27/15, and most recently updated 03/04/22, failed to include hypersexuality as a possible side effect of his medications, and failed to include goals and interventions related to hypersexuality.
Review of Resident R1's clinical record indicated that he received psychological counseling services 19 times from 2019, through 2022. The psychiatry clinical note dated 1/21/22, indicated: "Discharge from follow -up. We will remain available for consultation PRN (as needed)."
Review of Resident R1's clinical record indicated that he was reviewed by psychiatry on 6/17/21, 7/15/21, 12/21/21, and 1/14/22.
Review of facility census records and progress note indicated that Resident R1 was moved to the locked memory impaired unit on 1/24/22.
Review of facility census records and progress note indicated that Resident R1 would receive Nuplazid (used to treat hallucinations and delusions in people with psychosis from Parkinson's disease) 34 milligrams daily.
Review of physician order dated 1/25/22-2/9/22, indicated that Resident R1 would receive a tapered dose of Nuplazid 34 milligrams as follows: one tablet for three days, then one tablet every other day for seven days, then one tablet every three days.
Review of approximately seven years of progress notes (1/13/15-12/26/21) indicated one progress note indicated sexual behavior:
3/25/19, at 9:06 a.m. "Resident asked CNA (Certified Nurse Aide) "Will you play with my penis". CNA told the resident this was unacceptable quest to ask the CAN. Resident's call bell was on writer went to resident's room and asked resident what he had needed, at first resident replied "nothing" then asked, "Will you play with my dick?"
Review of approximately four months of progress notes (12/27/21-4/29/22) indicated eleven progress notes indicating sexual behavior.
Review of a progress note written by LPN Employee E14 dated 12/27/21, at 5:27 p.m. indicated, Resident noted to be in his room naked and laying in his bed holding his pillow inappropriately. When he noticed writer he jumped from his bed and covered himself."
Review of a progress note written by LPN Employee E1 dated 12/31/21, at 1:54 p.m. indicated, "resident being sexually inappropriate towards staff. Resident asked if he could see her "pussy" and stated for LPN to take her panties off while grabbing at LPNs arm. LPN left the room after telling the resident he was being inappropriate and needed to stop resident repeated his previously stated questions."
Review of a progress note written by LPN Employee E11 dated 1/1/22, at 9:45 p.m. indicated, "Writer entered room to give hour of sleep meds. Writer noted him prone in bed without clothingor night shirt. also no brief. writer questioned him as to why he had nothing on he stated "I'm playing with my butt."
Review of a progress note written by LPN Employee E1 dated 1/8/22, at 12:38 a.m. indicated, "resident was peeking into a female resident's room and attempted to go in even after being told that he should not go in there because it was a female resident's room. resident was stopped by staff and reminded he could not go into another person's room without their permission. resident huffed and walked down the hall peeking into other resident rooms."
Review of a progress note written by LPN Employee E14 dated 1/14/22, at 2:40 p.m. indicated, "Upon entering resident's room, noted curtain pulled. Called resident's name to alert him of my presence. Upon entering resident's area, he was noted to be completely naked and shuffling around on his bed."
Review of a progress note written by LPN Employee E11 dated 1/18/22, at 6:59 a.m. indicated, "resident spent majority of night shift masturbating and thrusting into mattress.
Review of a progress note written by the Director of Nursing dated 3/15/22, at 2:05 p.m. indicated, "LPN asked resident how he was feeling 3/14/22 at 4:30 p.m. due to his blood pressure being elevated the day before. Resident stated that he felt good, I wish I could go back home and have sex with that lady again." LPN asked what lady was he talking about, stated, "The one that lives down the road from my dad's house." LPN asked does your father know?" Resident did not answer anymore questions. Resident was on a leave of absence with father over this past weekend. Call placed to family and updated on statement. Per sister, their father lives on a desolate road and the neighbors are not close for him to walk to. He has to go down 20 plus cement stairs and walk up or down hills to get to a neighbor and would not be able to make it out of the house without assist from the father. The road is a side road that is hardly driven on and not well traveled. Sister stated that she would update the father about comment made."
Review of a progress note written by LPN Employee E17 dated 3/22/22, at 1:14 p.m. indicated, "while approaching pt for his afternoon meds pt said, "I told you I don't want anymore". Attempted to redirect pt and he said, "I'll take them if you do a dance on my peter". Redirected pt and told him that was inappropriate. He then stated that the last time he was home at his dads that he was playing with his "peter" on the street and went to the neighbor lady and asked her for sex and she called the police on him. He also stated his dad was mad at him and the cops came to talk to him."
Review of a progress note written by RN Employee E24 dated 4/12/22, at 7:17 a.m. indicated, "At approximately 12:00 a.m. overnight the resident was laying completely naked on his bed laying sideways. At 1:00 a.m. the resident was still laying on his bed without clothes with his legs over his head. When asked what he was doing he would not answer the question. At 2:00 a.m. the resident came running out of his room dressed in clothes swearing at the staff when he was reminded to use his walker. He said "if I fall, I fall. I don't care". A few minutes later the resident came back out of his room with his walker stating that now he feels he is having trouble
walking and he needed help sitting in a chair and standing up from the chair."
Review of a progress note written by RN Employee E26 dated 4/25/22, at 12:19 a.m. indicated, Called to hemlock unit by the floor nurse at 2250. Got to unit in resident's room was a female resident sitting on floor no bottoms on shirt unbuttoned. Staff reported another resident reported to them there is a man down the hall without any pants on. As staff going to said room observed this male resident dragging female resident on floor without pants on brief shredded on floor bed alarm sounded this male resident stated to staff he unbuttoned her shirt. Staff got female resident off floor to safe area 2 small scratches noted to female resident."
Review of a progress note written by LPN Employee E21 dated 4/25/22, at 1:04 a.m. indicated, "At approx. 2250 a resident came to nurses station stating there was a male resident with no pants on with privates out. Both NAs got to this resident's room before writer. Wheelchair alarm of other resident, which was a female, sounding at this time. NA reported to writer that this resident had another resident ' s legs up in the air pulling said resident across the floor. Other resident noted to not have pants or brief on, shirt unbuttoned. Other residents brief noted to be shredded and all over the floor. Other resident noted to be trying to get away from this resident by kicking legs. This resident first stated, "I didn't do it". Writer asked this resident how other residents shirt got unbuttoned. This resident said, "I did it". This resident also stated to writer and NAs "I was trying to put her in bed". This resident and other resident separated immediately. RN was notified immediately of situation by writer. 1:1 supervision of resident initiated immediately and will continue remainder of shift."
Review of a progress note written by RN Employee E31 on 4/29/22, at 1:25 p.m. indicated "Resident was then asked what kind of music he'd prefer and resident stated, "anything more fuckable.""
During a follow-up interview on 5/20/22, at 3:21 p.m. Psychiatrist Employee E42 stated that "all Parkinson's meds can cause hypersexuality." Psychiatrist Employee E42 confirmed that he had not been notified by facility staff that Resident R1 had displayed new sexual behaviors.
Review of all progress notes since admission failed to indicate any documentation of notification to psychology, psychiatry, or facility administration of increased sexual behaviors beginning in December 2021.
During an interview on 5/12/22, at 1:30 p.m. LPN Employee E1 stated that she remembered writing the above progress notes, and confirmed that Resident R1 had begun acting out sexually since December 2021, and the behaviors had escalated. LPN Employee E1 stated that the facility administration was aware of Resident R1 ' s behaviors, as he was moved from the open units to the memory impaired unit after she had asked facility administration to review his increasing behaviors. LPN Employee E1 further stated that his behaviors were disruptive to other roommates, and on multiple occasions, Resident R1's roommate would find other areas to sleep due to Resident R1's continual masturbation, lasting for hours at times.
The facility failed to implement adequate safeguards to protect cognitively impaired residents in a secured memory unit from sexual abuse, the facility failed to identify abuse as sexual and failed to assess residents current and past that may have/had the potential to be sexually abused, these failures resulted in an sexual assault on one Resident of 29 cognitively impaired residents (Resident R2).
An immediate jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing on 5/7/22, at 3:51 p.m. related to the facility's failure to protect Resident R2 from sexual abuse by Resident R1 and 29 cognitively impaired residents from the potential of being sexually abused by Resident R1. The immediate jeopardy template was provided to the facility on 5/7/22, at 3:51 p.m.
The corrective action plan included:
All residents in the secured unit were being assessed for any signs and symptoms of trauma/sexual abuse.
All incidents 60 days prior to the date of the event will be reviewed. Any incidents found will be fully investigated, and residents who have experienced such events will be assessed by a licensed provider and a sexual assault specialist will be contacted.
Whole house education will be provided on sexual and physical abuse.
Audit of all incident reports and progress notes will be audited by DON or designee for the next 60 days.
During staff interviews on 5/8/22, between 10:00 a.m. - 10:55 a.m. 20 staff members confirmed they received reeducation on sexual abuse, including the definition of sexual and physical abuse and actions to take if it is thought to have occurred. (1 Registered Nurse, 3 Licensed Practical Nurses, 9 Nurse Aides, 3 Dietary employees, 2 Environmental Services employees, and 2 Activities Department employees).
The immediate jeopardy was removed on 5/8/22, at 11:01 a.m. when the action plan was verified.
During an interview on 5/8/22, at 10:55 a.m. Nursing Home Administrator (NHA) confirmed on 4/24/22, Resident R2 was found with no pants/brief on in a room on the secured unit with his/her ankles being held by Resident R1 who was standing over Resident R2 with no pants and the facility failed to protect Resident R2 from sexual abuse and failed to identify the incident as sexual abuse, and the facility did not assess other residents on the secured unit to determine if they had been sexually abused resulting in an immediate jeopardy situation.
28 Pa. Code 201.14: (a) Responsibility of licensee.
Previously cited 2/11/21
28 Pa. Code 201.18: (b)(1) Management.
Previously cited 6/29/20
28 Pa. Code 201.18: (e)(1) Management.
28 Pa.Code: 201.18: (d)(1)(3) Nursing services
Previously cited 8/27/21, 2/11/21
| | Plan of Correction - To be completed: 06/22/2022
1. All residents in the Hemlock, memory lane unit, were assessed for any signs or symptoms of trauma and or sexual abuse by registered nurses that have been fully educated on what sexual and physical abuse is. i.e. changed behavior, unexplained physical changes, unexplained emotional changes, changes with community behavior or any signs of unrecognized abuse.
2. All incident reports, 60 days prior to the date of event, will be fully reviewed by a registered nurse who is educated on sexual and physical abuse, to identify any missed incidents that could have been sexual or physical in nature. Any incidents found will be fully investigated. Residents who may have experienced such an event will be assessed immediately by a licensed provider. The Pennsylvania State Police, crisis, medical director, Department of Health, primary care practitioner and family as well as area agency of aging will notify of incident.
- Director of nursing or designee will review all progress notes from January 1, 2022 to present to identify any missed incidents that could have been sexual or physical in nature. Any found will be fully investigated. Residents who may have experienced such an event will receive immediately assessed by a licensed provider. The Pennsylvania State Police, crisis, medical director, Department of Health, primary care practioner and family as well as area agency of aging will be notified of incident.
- Audit of all incident reports and progress notes will be audited by Don or designee for the next 60 days to ensure compliance.
3. Reeducation of NHA, DON and Cooperate Consultant will be performed by Paul McGuire Chief Operations Officer on May 7, 2022 on the definition of sexual abuse and proper action to take when identified.
4. Whole house education will be provided DON or designee on sexual and physical abuse to include but not limited to:
- the definition of sexual and physical abuse
- signs and symptoms of sexual and physical abuse
- what to do immediately to ensure safety of all residents
- reporting process of sexual or physical abuse
- Initial Whole house education will be completed as of today May 7, 2022 with any current employees who are working.
- Education will be provided to all current staff members before the start of their next shift.
- All current staff will be educated on sexual assault.
- Any new staff member hired will also be fully educated on sexual and physical abuse at the start of their employment.
5. All staff will be educated by a department of health provider, Lewis Litigation Support and Clinical Consulting LLC. F600 42 CFR 482.12(a)(1) completed 6/2/22, on Abuse and Neglect.
6. Results of the audits will be reviewed and recorded in monthly quality assurance meeting to ensure compliance.
7. Date Certain 06/22/22
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