cms_WV: 4007
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4007 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 223 | K | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, incident/accident reports review, facility reportable allegation(s) of abuse review, policy and procedure review, and staff interviews, the facility failed to ensure residents were free from sexual abuse. This was true for seven (7) residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s), who received nonconsensual sexual contact by Residents #10, #11, and/or #62 which were reviewed during the Quality Indicator Survey (QIS) and complaint investigation. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficient practice may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance.) A reasonable person, if touched inappropriately by another person putting hands his down ones pants, touching breasts, and/or rubbing genital area without consent in one's resident home, would feel fear, humiliation, anger, anxiety, and/or stress. These findings had the potential to affect more than a limited number of residents. Resident identifiers: #26, #39, #51, #49, #24, #37, #1, and #20. Alleged perpetrators: #10, #11, and #62. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. c) Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. d) Alleged Perpetrators: 1. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b) Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c) Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. [NAME] Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. d) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. e) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/26/17, found the resident's Brief Interview for Mental Status (MDS) score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated severely impaired cognitive functioning. She lacked capacity to make medical decisions. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility. She estimated that to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once, over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them bene | 2020-03-01 |