cms_WV: 4037
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4037 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 157 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to notify the resident's responsible party and/or physician of incidents of sexual abuse. This was evident for seven (7) of eight (8) residents reviewed for abuse. Resident identifiers: #51, #49, #24, #37, #1, #39, #26, #10, #62, #52, and #11. Facility census: 61. Findings include: a) Resident #51 Confidential Interviewees (CI) #3 and CI #4, in separate interviews, both said they had witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to whomever was 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. An incident report dated 12/08/16, described that Resident #51 was sitting 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. Review of the nurse progress report found no documentation on 12/08/16 about this incident between the two (2) residents. There was no evidence the facility informed the responsible party or the physician of these occurrences. b) Resident #49 During 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 that male Resident #11 and male Resident #62 were both separated from Resident #49 on 02/20/17 by other staff, but did not witness it herself. CI #1 said the nurses' reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff was aware that those two (2) male residents touched female residents inappropriately over their clothing. She said the incidents of the morning of 02/20/17 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 went real slow when he saw 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 the resident 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. The DON said staff should have filed an incident report any time this type of behavior was observed. She said had that been done, an investigation would have ensued. As part of the investigation, the family members and the physician would have been notified of the incidents. The DON reviewed the computer and her records, and said she found no other incident reports for this resident, and subsequently no evidence of notification of the resident's responsible party or the physician. c) Resident #24 During an interview, CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility, which she estimated as 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 him touching her. 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 covers were off the resident, 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. During an interview on 02/28/17 at 1:00 p.m., the DON said staff had not made her aware that a male resident(s) had inappropriately touched this female resident. The DON reviewed the computer and her records, and said she found no incident reports for this resident of that nature, and subsequently no evidence of responsible party or physician notification. d) Resident #37 CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. 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 the resident told him, No, and he jerked back his hand. During an interview on 02/28/17 at 1:00 p.m., the DON said she was not aware a male resident had inappropriately touched Resident #37. The DON reviewed the computer and her records, and said she found no incident reports for this resident of that nature, and subsequently no evidence of notification of the responsible party MPOA or physician. The DON said staff should have filed an incident report any time this type of behavior occurred. She said had that been done, an investigation would have ensued, and as part of the investigation, the family members and the physician notified. e) Resident #1 CI #11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub on Resident #1's legs and inner thighs. She said she reported this to the nurse in charge at the time. During an interview with the DON on 02/28/17 at 1:00 p.m., she reviewed the computer and her records, and said she found no incident reports for this resident of that nature, and subsequently no evidence of MPOA or physician notification. The DON said staff should have filed an incident report any time this type of behavior was observed. She said had that been done, then an investigation would have ensued. As part of the investigation, the family members and the physician would have been notified of the incidents. f) Resident #39 Medical record review found on10/09/16 at 6:46 a.m., Resident #11's behavior monitoring nurses' notes stated, Alert and oriented . Resident was up adlib (as desired) 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. Review of Resident #39's medical record, incident/accident reports, and reports made to State agencies, found no evidence the resident's responsible party was notified of the incident. g) Resident #26 On 10/06/16 at 18:40 (6:40 p.m.), an incident report noted Resident #62 (a male) was observed forcefully grabbing Resident #26 left arm. According to the report, Resident #62 attempted to reach Resident #26's crotch. At 18:47 (6:47 p.m.), Resident #62 was again found reaching for the crotch of Resident #26. Staff separated the residents and Resident #26 was transferred to the Second Floor. Review of Resident #26's medical record review, incident/accident review, and review of reports made to State agencies, found no evidence the facility notified the resident's responsible party of these incidents. h) Resident #62 An incident report identified the alleged perpetrator as Resident #62. Additional evidence was found when the SW noted On (MONTH) 16, (YEAR) (Resident #26's name - a female) 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. - 10/05/16 at 13:16 (1:16 p.m.) An Activities note stated Resident #62 was redirected at two (2) different times when he had his hand between an unidentified female resident's legs. - 10/06/16 at 10:06 a.m., a nurse noted Resident #62 was found reaching for the crotch of Resident #26. Again, at 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated and continued to follow. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes stated, Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurse's 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. Resident #62 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 medical record review, incident/accident review, and review of reports made to State agencies, found no evidence the facility notified the resident's responsible party of these incidents. i) Resident #10 This quarterly MDS also identified Resident #10 as having exhibited physical behaviors directed toward others, which included 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 his medical record found the following: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's 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.) an additional amended entry 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. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurses' notes stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident's room sitting 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 (certified nurse aides) 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/nurse's note 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 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 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. 12/11/16 at 2:51 a.m., Monthly Assessment nurses' 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 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. - 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 name #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 nurse's 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/nurses 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 nurse's note 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 Note 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. Review of the resident's medical record, incident/accident reports, and review of reports made to State agencies found no evidence Resident #10's responsible party was informed of any of these occurrences. j) Resident #11 Medical record review on 02/22/17 at 9:00 p.m. revealed the following about this male resident: - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated, Alert and oriented . Resident was up adlib (as desired) 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 - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurse's note for Resident #11 stated, Resident self-propelled wheelchair to up beside an unidentified female 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.' Review of the resident's medical record, incident/accident reports, and review of reports made to State agencies found no evidence Resident #11's responsible party was informed of any of these occurrences. k) In an interview with the Director of Nursing (DON) on 02/22/17 at 2:10 p.m., when asked to clarify if there was any information she could provide regarding notification of responsible parties when an incident of sexual abuse occurred, she stated No. When asked if an incident report had been completed would the incident report indicate the responsible party had been notified and she stated Yes, if an incident report had been completed. | 2020-02-01 |