cms_WV: 9398
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9398 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-11-15 | 224 | E | 1 | 0 | TJP411 | Based on medical record review, staff interview, and a review of the reportable allegations of abuse and neglect, the facility failed to ensure female residents were free from inappropriate sexual behavior by a male resident. Resident #89 had displayed inappropriate sexual behaviors toward four (4) female residents. Resident identifiers: #4, #24, #84, #74, and #89. Facility census: 89. Findings include: a) On 11/14/12 at approximately 10:00 a.m., a review of Resident #89's medical record revealed this resident had engaged in sexually inappropriate behavior toward four (4) female residents. A review of the general progress notes revealed a note from a registered nurse dated 10/05/12 at 2:20 p.m. The note stated, RN was notified by laundry staff at 7:07 pm that elder was observed by her touching a female resident in a sexual and inappropriate way in activities DR (dining room). RN (registered nurse) redirected elder to his room. Female elder was unable to verbalize situation or defend herself from it, however, she did not show any apparent signs of distress from it. While RN was escorting elder back to his room, elder would try to approach other female residents and attempt to show them his (genitals). Elder was left in his room, lying down at that time while RN went to get direction from policy/protocols for situation. By 7:45 pm both aides working that side of East Hall (Employee #9 and Employee #80 CNA), reported to RN that elder had been observed in 2 separate female resident's rooms undressing them. One of the lady's gown was pulled completely off and lying on her abd (abdomen) while he was attempting to get her bra off her. Elder was attempting to pull of the other lady's gown when aide walked in the room and noted situation. Both aides informed me that there was another female resident that is A&O (alert and oriented) to psn (person) & is very aware of her environment. Per aides, this lady verbalized and displayed fear towards elder, and stated elder tried to get in bed with her and was acting 'inappropriately' with her. RN notified (named physician) by 8pm and received orders to send elder to (name of psychiatric unit). After the incident at 7:07 p.m., Employee #99 (RN) assisted the resident back to his room and left him unattended. The facility had no evidence to show Employee #99 had informed other nursing staff of Resident #89's behavior on 10/04/12. The facility had not made an effort to ensure the immediate safety of other female residents after a male resident had displayed inappropriate sexual behaviors. Consequently, the resident wandered out of his room and into the rooms of three (3) other females where he displayed inappropriate sexual behaviors toward them. Employee #96 (director of nursing) indicated the facility did not have documentation showing they had ensured the safety of the female residents during this time. Nursing documentation, on 10/05/12 at 5:03 p.m., showed the facility transferred the resident to a local inpatient psychiatric unit on 10/05/12. Employee #96 (director of nursing) stated the facility did transfer the resident to the local emergency roiagnom on the night of 10/04/12. However, the exact time of this transfer was not documented. Employee #96 verified the resident returned to the facility after this transfer. The hospital told the facility they would inform them when a bed on the hospital's psychiatric unit became available. It remained unclear as to what time the resident returned to the facility on the night of 10/04/12. The facility did not have evidence they monitored the resident's behavior after he returned on 10/04/12. However, there was no indication any further female residents were subjected to inappropriate sexual behaviors after the incidents on 10/04/12 between 7:00 p.m. and 7:45 p.m. Employee #96 and Employee #98 (corporate registered nurse consultant) confirmed Employee #99 no longer worked at the facility. They provided a copy of the substantiated allegations of sexual abuse completed by the facility. The facility confirmed the four (4) female residents were victims of sexual abuse by Resident #89. | 2015-11-01 |