| 2816 |
LAKE EMORY POST ACUTE CARE |
425303 |
59 BLACKSTOCK ROAD |
INMAN |
SC |
29349 |
2019-04-25 |
607 |
G |
1 |
1 |
IJ5G11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment the facility failed to implement the facility policy to keep residents free from abuse. Resident #188, who had a well-documented history of sexually abusive behavior, sexually abused Resident #45. On 1/2/19 Resident #188 had his/her hand on a Residents crotch area, on 1/15/19 Resident #188 was noted with his/her hand in Resident #45's pants, with his/her hand in motion and on 2/3/19 Resident #188 placed his/her hand on a resident's genitals and rubbed. Additionally, the facility failed to report abuse to the state agency and investigate incidents dated 1/2/19 and 2/3/19 involving Resident #188. The facility failed to report incidents of sexual abuse dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188 to Law Enforcement. The facility failed to investigate abuse, Resident #187 made an allegation of abuse and the facility failed to interview the staff members involved or who had knowledge of the allegations. 2 of 5 residents reviewed for abuse The findings included: Resident #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Initial report on 4/22/19 at approximately 3:20 PM revealed Resident #188 touched Resident #45 without permission at approximately 11 AM on 1/15/19. Review of the 5-day report on 4/22/19 at approximately 3:25 PM revealed that Resident #45 was uninjured, both Residents #45 and #188 were cognitively impaired. Resident #188 had a prior history of sexually inappropriate behavior. One of the planned interventions was to move the victim to a further room. Review of Resident #188's nursing notes on 4/23/19 at approximately 10:05 AM revealed several notes documenting a history of sexually inappropriate behavior from Resident #188. Nursing note from 1/2/19 documenting that Resident #188 had his/her hand on a Residents crotch area, and the resident was immediately removed. Nursing note on 1/15/19 revealed Resident #188 was noted by 3 employees who took immediate action with his/her hand in Resident #45's pants, with his/her hand in motion. Nursing note on 2/3/19 documenting that Resident #188 placed his/her hand on a resident's genitals and rubbed. This was witnessed by several other residents. A witness (Resident) stated, I'm scared, and started to cry. Review of Resident #188 Care Plan on 4/23/19 at approximately 10:20 AM revealed Resident #188 was care planned to be taken to a private area for self-intimacy. There was no documented interventions to protect other residents from Resident #188's history of publicly masturbating while staring at female residents and groping female residents. During an interview with LPN #6 on 4/23/19 at approximately 12:08 PM revealed that Resident #188 put his/her hand into Resident #45's pants and moved hand up and down. Residents were immediately separated and the Nurse Practitioner assessed Resident #45. The family of both residents and management were immediately notified. LPN #6 stated that Resident #188 had a history of [REDACTED]. During an interview with Housekeeper #1 on 4/23/19 at approximately 12:44 PM s/he confirmed that Resident #188 had his/her hand in the pants of Resident #45. During an interview with LPN #7 on 4/23/19 at approximately 4 PM revealed that Resident #188 had his/her hand reached down the pants of Resident #45. When LPN #7 discovered this was happening, another nurse was already separating the two. LPN #7 knew of no other instances of Resident #188 touching residents. During an interview with the Administrator and review of Resident #188 and Resident #45's charts on 4/24/19 at approximately 8:50 AM revealed neither residents changed rooms after the incident. Record review revealed there was no evidence that Law Enforcement was notified of the incidents dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188. During an interview with the Administrator on 4/23/19 at approximately 12:15 PM revealed that incidents dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188 were not reported to Law Enforcement. It was also revealed that incidents dated 1/2/19 and 2/3/19 involving Resident #188 were not reported to the State Agency. Record review revealed that the only reference to the two incidents dated 1/2/19 and 2/3/19 were located in Resident #188's nurses notes. The notes did not provide the names of the other residents involved. During an interview with Licensed Practical Nurse (LPN) #6 on 4/23/19 at approximately 12:08 PM s/he confirmed that Resident #188 had attempted to sexually assault a resident at least one other time, though s/he was unable to name the specific date. There was no evidence that the facility investigated the incidents dated 1/2/19 and 2/3/19. Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed under Policy 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse . 2. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .Under section III. Prevention 5. Ongoing assessment, care planning, and monitoring of those patients/residents with special needs that may lead to neglect, for example: [NAME] History of aggressive behavior; B. History of entering other patient/resident rooms; C. History of self-injury; D. Communication disorder; and/or, E. Patients/residents requiring excessive nursing care or staff attention. F. Residents with history of resident to resident altercations. Under Component V. Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and the other officials in accordance with state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities). Review of Resident #188's record revealed that the resident was discharged from the facility on 2/7/18. The facility admitted Resident #187 on 10/16/18 with [DIAGNOSES REDACTED]. A review of the facility's abuse investigation on 4/24/19 at approximately 2:20 PM revealed that Resident #187 informed the facility on 10/30/18 he/she was neglected and verbally/mentally abused by the assigned physical therapist and a certified nursing aide. Further review of the facility's investigation documentation revealed there was no documentation to indicate the alleged perpetrator was interviewed. There was also written documentation provided by Certified Nursing Aide (CNA) #1 involved in the incident that revealed there was another CNA working with the resident on the unit at the time of the incident that was not interviewed. During an interview on 4/24/19 at approximately 2:35 PM with the facility Administrator revealed during his/her investigation into the allegations of abuse/neglect he/she failed to interview the alleged perpetrator and another CNA that was named in CNA #1 witness statement. Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed under Component VI: Investigation 1. The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. 5. The investigation may include but is not limited to the following: E. Written summaries of interviews with individuals having first-hand knowledge of the incident . |
2020-09-01 |