| 1129 |
SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, |
425112 |
807 SOUTH EAST MAIN STREET |
SIMPSONVILLE |
SC |
29681 |
2020-01-15 |
561 |
D |
1 |
0 |
62ZU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that 2 of 19 sampled residents (Resident #5 and Resident #6) were allowed to make personal choices and engage in intimate behavior in the privacy of their room. Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet in the Electronic Medical Record (EMR) revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located under the Care Plan tab of the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #6's face sheet, located under the Profile tab of the EMR revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS assessment with an ARD of 09/23/19, located under the MDS tab of the EHR, revealed a BI[CONDITION] score of 13, indicating he/she was cognitively intact. Further review of the MDS revealed no hallucinations, delusions, or behavioral concerns. Review of Resident #6's care plan, located under the Care Plan tab of his EMR, revealed a focus which read, I have an alteration in mood (as evidenced by) inappropriate sexual behavior, added 10/01/18. The interventions included, Divert my attention when possible and attempt to refocus me on something else. Review of Resident #5's Interdisciplinary Team (IDT) progress notes for, located under the Prog Notes tab of the EMR, revealed: 10/14/19 at 07:41 PM: . was brought to this nurses (sic} attention that this resident was being sexually inappropriate with (Resident #6) who entered (his/her) room . 10/14/19 at 7:53 PM: . (Resident #6) told to leave the room immediately, which (he/she) did . 10/14/19 at 9:08 PM: . (Resident #6) from earlier incident came down hall stating (he/she) was going to (Resident #5's) room to check on (him/her). Told was (sic) not a good idea and to return to (his/her) unit. (he/she) began swearing and yelling, entered room, told resident to leave door open, again swearing. Nurse entered room and asked (Resident #5) if it was ok for (Resident #6) to be there, (he/she) put thumb up. Staff at door for resident safety. (Resident #6) eventually left unit . nurse . in the meantime, had phoned authorities, who came and questioned both residents. (Resident #5) reported to authorities that they were friends who were watching tv (sic) and they did some kissing . During an interview on 01/14/19 at 10:45 AM the Social Services Director (SSD) stated he/she was aware of Resident #5's right to be sexually active, and that it was commonplace for Resident #5 to exercise that right. The SSD stated initially Resident #5 had a visitor from the community with whom he/she was intimate with in the facility, then later another resident (since discharged from the facility), then finally Resident # 6. The SSD stated while some staff had concern regarding Resident #5's relationship with Resident #6, the residents were both able to make their own decisions and could interact with one another as they chose. The SSD stated he/she was not sure why staff intervened the way they did when the event was discovered, based on Resident #5's known history and ability to consent. An interview with Resident #5's psychologist (Phy.D.) on 01/14/20 at 11:00 AM revealed he/she engaged in regular treatments with Resident #5 beginning in either June or July of 2019. Resident #5 had consistently shown the ability to make his/her own decisions and that Resident #5 had made his/her preference to engage in sexual activity at his/her own discretion known to the facility. The psychologist stated he/she was called in to evaluate Resident #5 the day after the event and Resident #5 was adamant that he/she had wanted the interaction to continue but Resident #6 was not allowed back in the room unattended. An interview with the Administrator on 01/14/20 at 11:45 AM revealed he/she became aware of the incident the following day. The Administrator stated that Resident #5's call light had been on, and as such it had been appropriate for the Certified Nurse Aide (CNA) to enter the room. The Administrator stated it was common knowledge amongst the staff that Resident #5 had been sexually active in the past and was uncertain as to why the CNA responded in that manner at the time of the event. During an interview on 01/14/20 at 2:00 PM, the Director of Nursing (DON) stated he/she was not in the facility but was called when the event occurred. The DON stated he/she instructed staff to interview Resident #5 to make sure he/she felt safe but gave no other direction. The DON stated Resident #6 was known to become angry at times so he/she wanted to make sure there was no anger involved. The DON stated if there was no anger involved and both residents consented to the interaction there should not have been a problem with the interaction continuing. An interview with CNA #5 on 01/14/20 at 3:00 PM revealed he/she was the staff person who discovered Resident #5 and Resident # 6's interaction. CNA #5 stated he/she had worked in the facility for [AGE] years and was aware of Resident #5's history of sexual activity. CNA #5 stated s/he did not know that Resident #5 was in an intimate relationship with Resident #6 and as such was not sure how to respond when he/she discovered the interaction. CNA #5 stated that he/she would have followed the care plan had one been in place. An interview with CNA #6 on 01/15/19 at 02:30 PM revealed s/he had been assigned as a one on one attendant for Resident #6 at the time the event was discovered with the assigned duty of keeping Resident #6 and Resident #5 apart. CNA #6 stated Resident #6 was calm that evening until he/she was told he/she could not return to visit Resident #5. CNA #6 stated at one point it was decided that Resident #6 could visit Resident #5 but the CNA was expected to keep the door open and observe the entire interaction. An interview with the Administrator on 01/15/19 at 03:00 PM confirmed the facility did not have a policy on resident visitation, but provided a copy of Resident Rights, which he/she reported each resident received upon admission. Review of the undated Resident Rights document provided by the Administrator revealed, . You have the right to spend private time with visitors at any reasonable hour. |
2020-09-01 |