| 18 |
KENTMERE REHABILITATION AND HEALTHCARE CENTER |
85001 |
1900 LOVERING AVENUE |
WILMINGTON |
DE |
19806 |
2018-12-06 |
608 |
D |
1 |
1 |
H65F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of the clinical record, facility documentation and other documentation as indicated, it was determined that for one (R45) out of 54 sampled residents, the facility: - failed to develop and implement written policies and procedures for covered individuals (included employees) that ensured reporting of crimes occurring in a federally-funded long-term care facility in accordance with section 1150B of the Social Security Act; - failed to report to the law enforcement entity for the political subdivision in which the facility was located any reasonable suspicion of a crime against any individual who was a resident of, or was receiving care from, the facility; and - failed to report not later than 24 hours if the event that caused the suspicion did not result in serious bodily injury. After the 11/7/18 allegation of sexual abuse of R45 (alleged victim) by E7 (accused nurse) was made by E10 (CNA), the facility failed to recognize its responsibility to report a suspected crime to the local law enforcement entity; failed to report a suspected crime not later than 24 hours later; failed to maintain the integrity of any evidence; and failed to transfer R45 to the hospital emergency department for a forensic examination until 2 days later. Findings include: Cross refer to F580, F607, F609 and F610 Review of the facility's Abuse, Neglect, Mistreatment, Misappropriation and Exploitation policy and procedure, effective (MONTH) (YEAR), stated under Procedure: .2 .b. Such training, if consistent with the individual's expected role, shall include: .iii. Reporting of crimes occurring in the facility .4. Investigation and Reporting. a. All alleged incidents involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property shall be reported to the administrator of the facility immediately. b. Thereafter, the administrator and other appropriate persons at facility shall investigate allegations pursuant to the Incident Investigation Guideline and make reports to appropriate officials as directed by federal and state law . The facility's policy and procedure failed to specify the following components under 42 CFR 483.12(b)(5): - Identification of who in the facility is considered a covered individual; - Identification of crimes that must be reported; - Identification of what constitutes 'serious bodily injury'; - The timeframe for which the reports must be made; and - Which entities must be contacted for example, the State Survey Agency and local law enforcement. Review of the R45's clinical record revealed: 10/2/18 - Review of a quarterly MDS assessment revealed that R45 was severely cognitively impaired and had active [DIAGNOSES REDACTED]. 11/7/18 at 6:30 AM - The facility's Incident/Accident Report stated the following: - R45, resident, was confused and disoriented before the incident; - Description of what happened: CNA alleged staff was inappropriately touching resident; - Physician notified at 6:30 AM; - POA notified on 11/8/18 at 9:45 AM. The facility's internal incident report failed to identify the accused staff member and failed to document the internal investigation and findings. 11/7/18 (untimed) - The facility conducted an internal investigation and obtained statements from the following staff: - E8 (CNA) stated, Today on 11-7-18 on shift 11-7 about 6:30 AM I headed toward the end of the hall to search for the nurse (E7). I stop in front of room (number). I see the resident (R45) lying on her side facing the window and the nurse bent down to her level. The resident was covered from the waist down. I see movement under the covers moving fast. I stepped back out of the room and stepped back into the doorway and called the nurses (sic) name. The nurse immediately pulled his hands from underneath the covers and covers the resident up with the blanket. He jumps back and then exits the room with me. - E9 (RN, House Supervisor) stated, On 11/7/18 at 6:45 AM E8 (CNA name) came to me to report that she had witnessed E7 (nurse name) doing something on (sic) Resident (R45's name). She witnessed that E7's hand is under R45's blanket and the blanket was moving very fast. Staff sent back to floor immediately to ensure resident's safety. - E7 (RN) stated, Toward the end of the 11-7 shift on 11/7/18 this nurse noted a skin check was due on the TAR. I performed the skin check on resident (R45) in rm (room number) while resident was lying in bed. Resident was awake & (and) @ (at) baseline level of orientation. I informed resident that I needed to check her skin and resident smiled, giggled and stated ok. I proceeded to assess her upper back, buttocks & groin area after lowering her hipsters then groin area proceeding to assess back of thighs & legs to heels & feet soles, ankles, dorsal aspect then toes, shins upper legs to groin & abdomen, upper chest arms neck, shoulders, neck & head. Resident appeared in no distress occasionally giggling & reaching out. Readjusted incontinence product & hipsters & covered resident c (with) bed linen & then proceeded to respond to request from CN[NAME] 11/8/18 at 9:45 AM - On the following day, the facility notified F6 (R45's POA) of the 11/7/18 allegation of sexual abuse involving R45. The facility failed to immediately notify F6 of the 11/7/18 allegation of sexual abuse until 27 hours later. 11/8/18 at 10:04 AM - The facility's reporting person, E2 (DON), notified the State Survey Agency of the 11/7/18 allegation of sexual abuse involving R45 (resident) and E7 (accused nurse). The facility reported: .CNA alleged that she saw a .nurse touch a resident inappropriately. CNA stated that resident was lying in bed and that the nurse was bent down to the resident level. The resident was covered with a blanket from waist down and the CNA stated she saw fast movement under the covers. The CNA stated she called the nurses name he pulled his hand out from under the covers. The nurse was interviewed and stated that the resident was lying on her left side and he was attempting to pull down her hipsters to assess her skin when the CNA called his name. A thorough assessment of the resident was completed and no signs of trauma was noted to the peri area. An internal (facility) investigation was conducted and completed and the allegation was found unsubstantiated. 11/8/18 at 1:49 PM - According to the local law enforcement's dispatch records, E1 (NHA) called the local law enforcement agency to report the 11/7/18 allegation of sexual abuse. A police officer, F3, was dispatched to the facility. The facility failed to identify its responsibility to report an allegation of sexual abuse involving a resident until approximately 33 hours after the incident occurred and at the insistence of R45's POA/family. 11/8/18 at 2:04 PM - According to the local law enforcement dispatch records, F3 left the facility. F3 did not write a report after meeting with E1 (NHA) and E2 (DON). 11/9/18 at 5:48 PM - According to the hospital record, R45 was seen and examined by the Emergency Department's Forensic Team two days after the alleged incident. F4 (hospital Forensic Nurse) notified the local law enforcement agency and the State Survey Agency (at 5:53 PM) that R45 was seen and examined for an alleged sexual assault of adult. 11/21/18 after 1 PM - According to email correspondence between F5 (Detective with the local Criminal Investigations Unit) and E1 (NHA) and E2 (DON), F5 met with E1 (NHA) and E2 (DON) regarding the 11/7/18 allegation of sexual abuse of R45. F5 requested documents and facility staff names and contact information. 12/5/18 at 9:43 AM - During an interview, E2 (DON) stated that on 11/8/18, F1 (family member) talked to F6 (POA) and F6 wanted the police to be called. E1 (NHA) stated we can do that. F1 stated that she will inform F6 that you are going to call the police. E1 called the police and an officer came out. We (E1 and E2) met with F3, the officer. F3 asked what happened and E1 explained from the CNA standing at the door what she said she saw, the statements that were written, order for the skin check, nurse did indicate that resident had hipsters on and he was shimmering them up. E1 had to explain what hipsters are to the officer. Officer said I can't take a report on a crime that wasn't committed. So E1 said that the family wanted us to call so can you give some kind of proof that you were here. Officer said they can call and make a complaint if they want and he said they have record of any calls that come in and who is dispatched out. E1 said can you give us something, do you have a card at least. Officer pulled out a blue generic card and wrote his last name on the card. E1 called F2 (R45's family member) and did let him know the police officer did come out, that he didn't take a report but did say they could call for a complaint and E1 gave F2 the number on the blue card and the officer's last name. F2 said fair enough and I will definitely pass this information along. 12/5/18 at 12:51 PM - During a telephone interview, F7 (hospital Forensic Nurse supervisor) stated it was their standard practice that if a dependent resident was evaluated for sexual assault to notify the police detective division and the State Survey Agency, if the resident was in a long-term-care facility. 12/5/18 at 2:10 PM - During an interview, E1 (NHA) stated that there were multiple calls going on with R45's family and they were not documented. E1 stated that she was keeping F2 (R45's family member) informed. E1 stated that F1 (R45's family member) came in and was upset. E1 stated the family asked for the police to be notified and she was unsure of the exact time. E1 stated that F3 (officer) arrived and we (E1 and E2, DON) told him what happened and what we found in our investigation. E1 stated that F3 didn't think there was a reason to take a report. E1 stated that she asked F3 for some kind of documentation from him and received a blue card with his name on it. E1 stated that F5 (Detective) came to the facility and he would notify me of the outcome of the investigation. E1 stated that E7 (accused nurse) was assigned to a different floor from R45. 12/6/18 at 8:45 AM - During an interview, this surveyor showed E4 (Medical Director) a copy of the facility's incident report for the 11/7/18 allegation of sexual abuse, which stated that E4 was notified at 6:30 AM and asked her if she remembered being notified. E4 stated that she was unable to remember exactly when she was notified. E4 stated that she remembered being told by E9 (RN, Supervisor) about the incident by hey did you hear ., but does not remember being officially notified about the incident involving R45. E4 stated that she would have immediately sent R45 to be examined at the hospital, as they are the experts, upon being told that there was an allegation of sexual assault. This surveyor said that E4 ordered R45 to be sent to the hospital's Emergency Department to be examined on Friday, 11/9/18, two days after the incident occurred. E4 stated that it was her practice that if she was notified of an allegation of a sexual assault, she would immediately send the resident to the hospital to be examined by the Forensic Team. 12/6/18 at 9:09 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON). This surveyor asked who notified E4 (Medical Director) on 11/7/18 at 6:30 AM, E2 and E3 both said neither one notified E4. 12/12/18 at 10:48 AM - During an interview, F6 (POA) stated that she told F1, a family member, that she wanted a police report. F6 stated that F1 went to the local police station to file a report of the 11/7/18 allegation of sexual abuse and the police told her that she could not file a report, the facility had to file a report. F6 stated that F1 went back to the facility and met with E1 (NHA). 12/14/18 at 11:24 AM - During a follow-up interview, F6 (POA) stated that after she was notified about the allegation on 11/8/18 at 9:45 AM and given the phone number of the State Survey Agency, F6 asked E1 (NHA) if law enforcement was called. F6 stated that E1 told her it would be up to the family. F6 stated she was unable to give an exact time of when this discussion occurred on 11/8/18, but stated it occurred before the facility reported the allegation to the State Survey Agency (on 11/8/18 at 10:04 AM). F6 stated that she was on the phone to the State Survey Agency immediately after being notified of the allegation. F6 stated that she asked a representative of the State Survey Agency if they call the police, and F6 was told no that the facility had to call the police. 12/14/18 at 12:30 PM - During an interview, F1 (R45's family member) stated that she arrived at the facility on 11/8/18 between 11:30 AM and 12 Noon to check on R45 after talking to F6 (POA), who was out of state. F1 stated she went immediately to R45's room. F1 stated that she was greeted by E18 (LPN) and asked if F1 was here about R45's bruise. F1 stated no and she told E18 about the 11/7/18 incident involving R45. F1 stated that E18 was not aware of the allegation of sexual abuse. F1 stated that E1 (NHA), E2 (DON) and E16 (former DON) met her on R45's floor and spoke to her in R45's room. F1 stated that she asked E1, was the police involved? F1 stated that E1 said no, she was going to call the authorities but she didn't after she spoke to everyone and the accused nurse was doing what he was supposed to, a skin check. F1 stated that E1 said that E7 (accused nurse) was nice, worked here for (number) of years and had no incidents with the nurse. F1 stated that she called F6 (POA) and F6 said she wanted a police report. F1 stated it was around lunchtime and no one was around. F1 stated that she drove to the local police station to make a report. F1 was informed by a staff person at the police station that she could not make a report and that the facility would have to make a report. F1 stated that she returned to the facility and met with E1 (NHA). F1 stated that they (F1 and E1) tried calling the phone number given to her at the police station and there was no answer. F1 stated that she had to leave the facility. F1 stated that E1 (NHA) offered to call the police and make the report. F1 stated that E1 told her she would call F1 once she got through to the police. F1 stated that E1 called her after she got through to the police. The facility failed to develop and implement written policies and procedures for covered individuals (included employees) that ensured reporting of suspected crimes occurring in a federally-funded long-term care facility in accordance with section 1150B of the Social Security Act. The facility failed to identify its responsibility to report a suspected crime to the local law enforcement entity after the 11/7/18 allegation of sexual abuse of R45; failed to report a suspected crime not later than 24 hours later; failed to maintain the integrity of any evidence, failed to transfer R45 to the hospital emergency department for a forensic examination, which occurred 2 days after the 11/7/18 allegation of sexual abuse. |
2020-09-01 |