| 20 |
KENTMERE REHABILITATION AND HEALTHCARE CENTER |
85001 |
1900 LOVERING AVENUE |
WILMINGTON |
DE |
19806 |
2018-12-06 |
610 |
D |
1 |
1 |
H65F11 |
> Based on interviews and review of facility and other documentation as indicated, it was determined that for one (R45) out of 54 sampled residents, the facility failed to have evidence that an alleged violation was thoroughly investigated. In response to the 11/7/18 allegation of sexual abuse of R45, the facility failed to thoroughly investigate and failed to document the investigation/findings involving R45 and E7 (facility nurse). Findings include: Cross refer to F580, F607, F608 and F609 The facility's Incident/Accident Report of the 11/7/18 allegation of sexual abuse involving R45 and E7(facility nurse)stated: - incident date/time: 11/7/18 at 6:30 AM; - location of incident: R45's room number; - resident's condition before the incident: confused and disoriented; - height of bed: adjustable=yes, down=yes; - describe exactly what happened, why it happened, causes: CNA alleged staff was inappropriately touching resident; - type of injury: none; - name/time of physician notified: E4 (Medical Director) at 6:30 AM; - name/time of resident representative notified: F6 (POA) on 11/8/18 at 9:45 AM; - person seen by physician: no; - person taken to hospital: no; - name/title/contact information of witness: E8 (CNA); - additional comments and/or steps to prevent recurrence: blank; - signature of person preparing report/date: E2 (DON), 11/8/18; - signature of Director of Nursing: E2, 11/8/18; - signature of Medical Director: E4, 11/17/18; - signature of Administrator: E1, 11/8/18 Handwritten statements of E7 (accused nurse), E8 (CNA) and E9 (RN, House Supervisor), all dated 11/7/18, were attached to the Incident/Accident Report. The facility's incident report failed to identify the accused nurse and failed to document the internal investigation and findings. 11/8/18 at 10:04 AM - According to the facility's Incident Report submitted to Delaware's Office of Long Term Care Resident Protection (OLTCRP), the facility stated, Initial and 5 day combined. 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 investigation was conducted and completed and the allegation was found unsubstantiated. The facility's investigation lacked evidence of: - the immediate consultation with E4 (Medical Director) of the allegation of sexual abuse to determine the potential need of physician intervention; - any interviews conducted with facility staff directly involved and other facility staff on duty during and following the 11/7/18 allegation; - assessment of R45's room, the area involved in the allegation, and securing any possible evidence associated with the allegation; - ongoing monitoring of R45 by staff after the 11/7/18 allegation; - reviewing of video surveillance on the floor around the time of the incident; - addressing further questions (why was the bed at the lowest level? were gloves worn during the skin assessment? why was R45's door open to the hallway? what was the lighting in R45's bedroom during the skin assessment?); and - documentation of multiple communications that occurred between facility staff and R45's POA/family. 11/8/18 at 10:04 AM - After the facility completed and unsubstantiated their internal investigation as per the statement submitted to the OLTCRP, the facility did the following: - notified the local law enforcement agency at the POA's insistence of a police report during the afternoon of 11/8/18, approx. 33 hours after the allegation; and - sent R45 to be examined by the hospital's Forensic Team for sexual assault of adult according to hospital records during the afternoon of 11/9/18, two days after the allegation. 12/3/18 at 6:57 PM - During an interview, E26 (CNA) stated that she was assigned to R45 on 11/7/18 during the 7AM - 3PM shift following the incident. E26 stated that she was not told about the incident involving R45 before providing morning care, which included peri-care. There was no evidence that E26 was interviewed at any time regarding any changes in R45's behavior or physical appearance. 12/4/18 at 12:25 PM - During an interview, E18 (LPN) stated that he worked the 7-3PM shift on 11/7/18 following the incident. E18 stated that he was not told about the incident until approached by F1 (R45's family member) on 11/8/18, one day later. There was no evidence that E18 was interviewed at any time regarding any changes in R45's behavior. 12/5/18 at 2:10 PM - During an interview, E1 (NHA) stated that E7 (accused nurse), E8 (CNA) and E9 (RN, House Supervisor) were interviewed and provided handwritten statements. E2 (DON) checked if R45 was scheduled for a skin check and she was. There were multiple calls going on with the family. E1 stated it was not documented. E1 was asked by this surveyor if staff were observing for any changes with R45 after the incident and E1 replied, I can't say 100% sure. 12/5/18 at 4:46 PM - During an interview, this surveyor asked E1 (NHA) about the video surveillance on the floor and if the video on 11/7/18 was available to be viewed. E1 stated that she would ask IT (Information Technology). The facility failed to consider that the video was a potential source for information. 12/6/18 at 8:46 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 alleged incident. 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. The facility failed to immediately notify E4 of the 11/7/18 allegation of sexual abuse. 12/6/18 at 8:56 AM - During an interview, E1 (NHA) provided this surveyor with a copy of the surveillance video that was available, however, it did not capture the incident date of 11/7/18. 12/6/18 at 9:09 AM - Findings were discussed with E1 (NHA), E2 (DON) and E3 (ADON). In response to the 11/7/18 allegation of sexual abuse of R45, the facility failed to thoroughly investigate and failed to document the investigation/findings involving R45 and E7 (facility nurse). |
2020-09-01 |