| 2632 |
THE RIDGE REHABILITATION AND HEALTHCARE CENTER, LL |
425293 |
226 WA REEL DRIVE |
EDGEFIELD |
SC |
29824 |
2019-12-12 |
607 |
E |
1 |
0 |
YLVU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review, and review of facility policy, the facility did not ensure the Abuse Prohibition and Abuse Investigation Policy contained required information regarding investigating sexual abuse for 4 of 6 residents (Residents #7, #8, #9, and #10) reviewed for sexual abuse allegations. Resident #7 sexually assaulted Resident #8, and Resident #9 and #10 were engaged in sexual activity. The facility abuse policy did not contain information how to investigate each resident's capacity to consent to sexual activity. The findings included: Review of the facility Abuse Prohibition policy and the facility Abuse Investigations policy, both revised August 2019, revealed there was no information related to investigating a resident's capacity to consent to sexual activity in a resident to resident alleged sexual abuse incident. Review of facility incident dated 8/23/18 revealed CNAs #4 and #12 witnessed Resident #7 wheel up to Resident #8, who was in her wheelchair in the television area. CNAs #4 and #12 witnessed Resident #7 stroke Resident #8's thigh and groin area. CNA #12 wrote in her statement that Resident #7 was patting between his legs and saying he wanted some (name for female genitalia). Review of facility incident dated 3/13/19 revealed on 3/8/19, RN #1 heard a chair alarm and call bell going off in Resident #9's room. When RN #1 entered the room, she found Resident #9 and Resident #10 engaged in sexual activity. The facility investigation determined the incident was substantiated and did occur. In an interview on 12/11/19 at 5:06 p.m., the administrator stated there was no formal written policy to determine the capacity for a resident to consent to sexual activity, whether they had cognitive impairment or not. Review of Centers for Medicare and Medicaid Services State Operations Manual Appendix PP F[AGE]0, revised 11/22/17, revealed When investigating an allegation of sexual abuse, the facility must conduct a thorough investigation to determine the facts specific to the case investigated, including whether the resident had the capacity to consent and whether the resident actually consented to the sexual activity. A resident's voluntary engagement in sexual activity may appear to mean consent to the activity; in these instances, if the facility has reason to suspect that the resident may not have the capacity to consent, the facility must protect the resident from potential sexual abuse while the investigation is in progress. Determinations of capacity to consent depend on the context of the issue and one determination does not necessarily apply to all decisions made by the resident. For example, the resident may not have the capacity to make decisions regarding medical treatment but may have the capacity to make decisions on daily activities (e.g., when to wake up in the morning, what activities to engage in). Determinations of capacity in this context are complex and cannot necessarily be based on a resident's [DIAGNOSES REDACTED]. Decisions of capacity to consent to sexual activity must balance considerations of safety and resident autonomy, and capacity determinations must be consistent with State law, if applicable. The facility's policies, procedures and protocols, should identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded. |
2020-09-01 |