cms_WV: 4009
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4009 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 225 | E | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, policy and procedure review, accident/incident reports review, allegations of sexual abuse review, and staff interviews, the facility failed to ensure incidents of sexual abuse were identified, thoroughly investigated and reported to the appropriate State agencies. The failure to identify and investigate allegations of sexual abuse also resulted in a failure to ensure alleged victims were protected from further potential abuse. This was true for seven (7) female residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s) who were the recipients of nonconsensual sexual contact by Residents #10, #11, and/or #62. Facility census: 61. Findings include: a) Resident #26 1. Review of the resident's 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) (name of Resident #26) 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. A review of the report sent to the State agencies contained the immediate reporting form, the five-day follow up report, and the report to the Ombudsman and Adult Protective Services (APS). In an interview with the Social Worker (SW) on 02/24/17 at 11:38 a.m., when asked for the witness statements for this incident, she responded, I don't have any witness statements. When asked if the Director of Nursing (DON) or the Nursing Home Administrator (NHA) would have any additional information such as witness statements, the SW replied No. She stated, I did witness statements a long time ago, but haven't for a while. In addition, when asked about reporting the event between Resident #26 and Resident #62, the SW was asked how she determined this was a resident to resident altercation and not sexual abuse. The SW stated she did not consider it sexual abuse, but agreed in retrospect it was sexual abuse. 2. On 10/06/17 at 10:06 a.m., a nursing entry noted Resident #62 was found reaching for the crotch of Resident #39. Again at 18:47 (6:47 p.m.), Resident #62 was found reaching for the crotch of Resident #39 and residents were separated. An incident report, dated 10/06/16 at 18:40 (6:40 p.m.) stated Resident #62 was observed to forcefully grab 2B's (Resident #26) L (left) arm as she was ambulating via wheelchair past resident. Resident observed to attempt to reach with other hand toward resident's crotch. The Contributing Factors section of the report stated Resident redirected several times to stay away from 2B. Resident sat and watched her go up long hall and back down before grabbing her. The Prevention section of the report stated Resident is continually monitored for sexual inappropriateness against this resident. Residents are separated and whereabouts monitored as closely as possible by staff. This incident report was signed by a Licensed Practical Nurse (LPN #183) and noted to have two (2) witnesses only identified by first name and job title. The physician notification was originally marked as Yes and then marked through with no date/time of notification. The Director of Nursing, Administrator, and Social Worker signed the report on 10/10/16. The Medical Director who was also the attending physician signed the incident report on 11/01/16. The Social Worker, DON and Administrator confirmed this incident of sexual abuse was not reported to any State agency on 02/27/17 at 3:12 p.m. No evidence was found to support the resident was protected from further nonconcensual sexual contact. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's annual MDS with an ARD of 06/16/16, identified the resident had problems with hearing, speaking, and/or vision, and was usually able to make herself understood and to ususally understand others. The resident's Brief Interview for Mental Status (BIMS) score was 99, inidcating the interview could not be completed. BIMS scores on her quarterly MDSs, completed on 09/15/16 and 12/15/16, were 01 and 02 respectively. Both BIMS scores indicated severe cognitive impairment. A continuing review of the medical record for Resident #39 found an amended Monthly Nurse's Notes on 02/05/17 at 17:37 (5:37 p.m.) stating sexual behaviors with male resident. An additional amended Nurse's on the same day at 17:40 (5:40 p.m.) stated touching inapportiatlity (sic) other males. On 02/05/17 at 15:32 (3:32 p.m.) in a CNA/Nurse's Note stated Resident (#10) in female resident room, she (Resident #39) 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 attempting to pull her hand away when entering room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. On 02/01/17 at 6:42 p.m. 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 and were showered. The MDS Coordinator stated on 02/03/17 at 9:06 a.m., in a behavior monitoring nurse's note for Resident #10 that the SW, DON and NHA 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. In an interview with the social worker (SW) on 02/28/17 at 11:04 a.m., she stated she had been informed that Resident #10's [MEDICAL CONDITION] bag had come off and Resident #39 had been covered in stool. The SW had been told that when these two (2) residents were in a room together, it was consensual sex. She stated she informed Resident #39's responsible party and was told that sex would not be consensual and there was to be no sexual contact with this resident. Ask if she reported this incident to any of the appropriate State agencies and she stated No. c) Unidentified Female Residents Between (MONTH) (YEAR) and (MONTH) (YEAR), there were twenty (20) incidents where alleged perpetrators Residents #10, #11 and #62 were observed by staff committing non-consensual sexual acts. Through interviews with the Social Worker, Director of Nursing and Administrator, staff interviews, review of accident/incident reports, events reported to the appropriate state agencies and resident medical record review, no evidence was found these events were considered sexual abuse and therefore not reported to the appropriate State agencies. As stated by the Administrator, on 02/28/17 at 3:15 p.m., the system failed. If there were no incident reports completed, the events were not made known to administrative staff to report and investigate and therefore we did not investigate the events and report as per our policy. 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 this resident had 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, said they had 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. Review of the occurrences reported to State Agencies (SA) for the past year found none related to these staff interviews. 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 the physician and the administrator on 01/11/17. Review of the occurrences reported to the SAs for (YEAR) and (YEAR) found no evidence this event was reported to the required State Agencies. In 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. The DON telephoned the licensed social worker (LSW), who confirmed there was no report made to State agencies of the 12/08/16 event. The DON said this incident should have been reported to State agencies and investigated, and it was not. She said staff failed to follow the facility's abuse policy. An interview was completed with the licensed social worker (LSW) on 02/28/17 at 2:30 p.m. She said anything that is deemed abuse, neglect, or misappropriation of property is sometimes reported to her. Sometimes she finds it on her own. She said neglect also included not being taken care of by staff, and sexual things. She said she, the DON, the administrator, the nurse manager, and the secretary met daily Monday through Friday. At that meeting, they discussed incidents, but said they do not always get the incidents the day they occur, for whatever reason. The LSW said she was not made aware on 12/08/16 of the incident between Resident #51 and Resident #62. She said had she been made aware of this incident at that time, she would have completed an investigation, and reported to State agencies. d) Resident #49 On 02/22/17 review of the resident's medical record found the most recent quarterly minimum data set (MDS), with assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03), indicating severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. In separate confidential interviews with CI#1, CI#2, CI#6, CI#10, and CI#11, all five (5) said they had 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 she did not witness it, but other staff removed male Resident #11 and male Resident #62 from Resident #49 on 02/20/17. CI #1 said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware those two (2) male residents touched 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 occurred. 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. Review of the occurrences reported to State agencies for the past year found none related to the incidents described in staff interviews. e) Resident #24 On 02/22/17 medical record review of the most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/26/17, found her Brief Interview for Mental Status (MDS) score was four (4), indicating severe cognitive impairment. The assessment identified she had fluctuation of inattention and disorganized thinking. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents since his admission to the facility. She estimated this 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 Resident #24's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because, He scared the crap out of her. She said she heard Resident #24 tell him to leave. CI #11 said she reported this to the nurse in charge at the time. Review of incidents reported to State agencies in the past year found none related to these staff interviews. f) Resident #37 On 02/22/17, review of the resident's annual minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a BIMS score of two (2), indicating severe cognitive impairment. She also had inattention and disorganized thinking present that fluctuates over time assessed. Pertinent [DIAGNOSES REDACTED]. CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she told Resident #62 that he did not need to go into those ladies' rooms, to which he replied, She wanted it. She said she always reported the inappropriate behaviors to the nurse in charge. CI #5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. She said she told him no, and he jerked back his hard. Review of the incidents reported to the State agencies for the past year found none related to these staff interviews. g) Resident #1 On 02/22/17, review of the resident's quarterly minimum data set (MDS), with an assessment reference date (ARD) of 09/01/16, found her assessed to have a BIMS score of twelve (12). The MDS with an ARD of 12/01/16 assessed her BIMS score as nine (9). Both scores indicated moderately impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. CI#11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub on Resident #52's legs and inner thighs. When she saw him do that, she told him he could not do it and made him leave. He replied that he did not do anything. She said she reported this to the nurse in charge at the time. Review of the incidents reported to State agencies for the past year found none related to these staff interviews. On 02/22/17 at 10:00 a.m., Resident #1 was playing bingo by herself unassisted in activities, and able to carry on conversation. When asked if any of the men here at the facility have touched her inappropriately in private parts of her body, she replied in the negative. She said she would not put up with that. h) On 02/28/17 at 1:00 p.m., the information received during the confidential interviews was discussed with the director of nursing (DON). The occurrences reported during these interviews were: - One staff member reported witnessing Resident #62 inappropriately touche Resident #51. - One or more staff members said they witnessed Resident #62 and Resident #11 inappropriately touch Resident #49. - One or more staff members said they witnessed Resident #62 inappropriately touch Resident #24. - One or more staff members said they witnessed Resident #10 inappropriately touch Resident #37. - One or more staff members said they witnessed Resident #52 inappropriately touch Resident #1. The DON said she was not made aware by the staff that those female residents were inappropriately touched by those male residents, except for one day recently. She said that on 02/20/17 staff reported that Resident #49 was touched inappropriately by two (2) male residents the same morning. She said staff completed incident reports and reported to State agencies for those two (2) events. The DON said staff should have filed an incident report any time this type of behavior was observed, and this was not done. She said had that been done, then an investigation would have ensued. The DON said their facility policy explained that unwanted sexual touch was sexual abuse, and that those occurrences should be reported to State agencies. She said the reporting to State agencies was not done because there was no incident report completed on inappropriate sexual touching. She said an investigation was not done because there was no incident report completed for those behaviors. She said the first step was getting the incident report completed, and any staff member could begin an incident report. She said she reviewed the incident reports daily. If there are any incident reports which require reporting to State agencies, then those incidents were assigned to the licensed social worker for follow-up. i) During an interview was with the licensed social worker (LSW) on 02/28/17 at 2:30 p.m., it was discussed that one or more staff members in confidential interviews said they had witnessed inappropriate touching of female residents by male residents. Those female residents inappropriately touched were Residents #51, #49, #24, #37, and #1. The LSW said she was aware Residents #62, #11, and #10 had sexual behaviors. She said staff should have completed incident reports each time not only for the male perpetrator, but also for the female victim. She said apparently nurses do not do so. She said there are some things we need to work on and change to ensure the responsible parties of victims were notified, incident reports were completed, and the safety of female residents was ensured. The LSW said she has never heard of any inappropriate touching by Resident #52. She said Resident #52 and Resident #1 liked each other, but they did not even hold hands and she had never seen any inappropriate behaviors between them. j) In an interview on 02/28/17 at 4:38 p.m., the administrator acknowledged facility staff did not identify all issues of inappropriate touching and/or sexual abuse they were aware, or should have been aware of, as abuse situations. She said the lack of incident reports of abuse situations led to the absence of investigation into those issues, and failure to report all incidents of abuse to appropriate state agencies. She agreed that these practices led to the failure to protect some of its female residents from further abuse. | 2020-03-01 |