ALDEN HEATHER REHAB & HEALTH CARE CENTER
Facility I.D. Number0023945
Date of Survey:12/07/01
Notice of Violation:01/17/02
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the
administrator, the advisory physician or the medical advisory committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.
The facility shall notify the residents physician of any accident, injury, or significant change in a residents condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days. The facility shall obtain and record the physicians plan of care for the care or treatment of such accident, injury or change in condition at the time of notification.
A FACILITY ADMINISTRATOR WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER BY TELEPHONE AND IN WRITING TO THE RESIDENTS REPRESENTATIVE.
A FACILITY ADMINISTRATOR, EMPLOYEE, OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL ALSO REPORT THE MATTER TO THE DEPARTMENT.
RESIDENT AS PERPETRATOR OF ABUSE. WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT ANOTHER RESIDENT OF THE LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT RESIDENTS CONDITION SHALL BE IMMEDIATELY EVALUATED TO DETERMINE THE MOST SUITABLE THERAPY AND PLACEMENT FOR THE RESIDENT, CONSIDERING THE SAFETY OF THAT RESIDENT AS WELL AS THE SAFETY OF OTHER RESIDENTS AND EMPLOYEES OF THE FACILITY.
These regulations are not met as evidenced by:
Based on observation, record review, staff and other interviews, the facility failed to protect a confused, non-verbal resident, (R#1), after a sexual assault, failed to notify authorities after the alleged physical sexual attack occurred in the facility, and failed to implement their own abuse policy and procedures.
Observation of R#1 on 11/30/01 at 10:00 A.M. with E#11 on the second floor, surveyor observed R#1 walking with supervision with E#6. R#1 is alert but confused. R#1 can only communicate by simple one word answers.
Review of R#1's medical record reveals R#1's diagnoses are Dementia, Psychotic Disorder and Degenerative Joint Disease. The nursing assessment dated 11/1/01 reveals R#1's cognitive skills and daily decision making are impaired; it is scored at a level 3 (supervision required). Ability to make self understood is scored at a level 3, (rarely/never understood). R#1's ability to understand others is scored at a level 2, (responds to simple, direct communication).
Interview with E#6, E#7 and E#8 on 11/30/01 at 10:00A.M. in the nursing supervisor's office revealed that R#1 is total care and needs assistance with all Activities of Daily Living (ADL's). R#1 cannot communicate her needs or concerns verbally to anyone.
Review of R#2's medical records reveals R#2 has diagnoses of Herniated disc and Central Cord Syndrome. The nursing assessment dated 10/10/01 reveals he is independent with all ADL's.
Phone interview with E#5 on 12/4/01 at 10:00A.M., revealed that at about 12:00A.M. on 11/29/01 she observed R#2 guiding R#1 to his (R#2's) bedroom. E#5 stopped R#2 and assisted R#1 back to her room. E#5 assisted another resident, which took about 10 to 15 minutes. Then E#5 decided to check on R#1 again. E#5 said R#1 was not in her bed and called E#4 for help to find R#1. E#4 and E#5 searched the entire floor and when E#5 reached R#2's room she heard R#1 saying, "No, no, no," in a very low voice. E#5 began to enter the room and had a difficult time opening the door. E#5 noticed there was a night stand against the door. E#5 said she pushed the door open very hard and saw R#1 lying on R#2's bed on her back and R#2 was on top of R#1. R#1's right leg was bent and the left leg was straight and her gown was above her breast. R#2's pants and underwear were around his ankles. R#2 was doing an up and down motion with the lower part of his body. E#5 told R#2 to stop and get up and R#2 said, "It's my word against yours".
Phone interview with E#4 on 12/5/01 at 10:00A.M. revealed that she entered the room after E#5. E#4 said she saw R#2 pulling up his pants and R#1 on the bed with her legs open and her gown up over her breast.
Phone interview of E#2 on 12/5/01 at 10:15A.M., revealed that she did not witness any activity
between R#1 and R#2, but did see R#1 in R#2's room after the incident in the early morning hours.
In a phone interview with E#3 on 12/5/01 at 9:45A.M., E#3 told surveyor that E#1 was called at home on 11/29/01 between 12:15AM and 12:30A.M. to tell him about the activity between
R#1 and R#2. E#3 told surveyor she told E#1 R#1 was in R#2's room and R#2 was on top on R#1. R#2's pants and underwear were around his ankles and R#1's gown was above her breast. E#3 said ," (E#1) gave instructions to do an incident report and to have (E#4) and (E#5) write on a piece of paper everything they observed. (E#1) also gave instructions not to chart the incident in the chart, not to call the local police and not to call the physician".
Phone interview with E#2 on 12/5/01 at 10:15AM also confirmed that E#1 was told of the activity between R#1 and R#2 on the phone on 11/29/01 at 12:30A.M.
Phone interview with E#4 on 12/5/01 at 10:00A.M., revealed that E#1 was told of the activity between R#1 and R#2 on the phone on 11/29/01 at 12:30A.M.
Phone interview with E#5 on 12/5/01 at 10:05AM, revealed that E#1 was told of the activity
between R#1 and R#2 at 12:30A.M. on the phone 11/29/01.
Phone interview with E#2 on 12/5/01 at 10:15A.M., revealed that E#4 and E#5 put R#1 back into her room, which was only 40 to 50 feet away from R#2's room. R#2 remained in the facility in his room and nothing was done .
In a phone interview with Z#3 on 12/6/01 at 3:30P.M., Z#3 told surveyor he was not notified of the alleged sexual assault on 11/29/01 in the early hours of the morning. Z#3 said he would remember if anyone called him in the early hours of the morning telling him about an alleged sexual assault. E#1 told Z#3 that R#1 was in R#2's room and no further explanation was given.
The local police department was not notified until 11/29/01 at 7:00P.M. of the incident, 18 hours after it occurred. The family called the police, not the facility, according to the police report.
R#1 was not transferred to the hospital until 11/29/01 a 7:30P.M. for further evaluation when the family requested a transfer. Nursing notes dated 11/29/01 state R#1 was seen in a fetal position in bed and an assessment was made of pain in R#1's lower abdomen and vaginal pain. The family requested R#1 to be sent again to the hospital for further follow-up.
The facility's abuse policy was not followed by the staff in the facility. The policy states:
3. The alleged perpetrator shall be removed from further contact with residents.
3b) If the alleged perpetrator is a resident, an immediate evaluation will be conducted to determine the most suitable therapy and placement for the resident.
This was not done. R#2 stayed in the facility for 25 hours after the incident. R#2 was not removed from the facility until the local police arrested R#2 for rape. According to the police report, R#2 was taken out of the facility on 11/30/01 at 2:00A.M. Z#2 was not notified until 11/30/01by E#1 in the afternoon according to nursing notes.
The facility's policy further states:
The following notification of suspected abuse will be made with corresponding documentation:
a. Notification of local law enforcement agency. (This was not done until 18 hours after the incident and was initiated by the family per police report.)
4. The alleged victim will be assessed for any injuries or emotional distress. The resident's physician will be contacted and orders carried out by facility staff. R#1's physician was not notified until 18 hours after the incident by E#1 at 7:30P.M. and the physician was not told the details of the incident, according to phone interview with Z#2.
The facility's policy further states:
5. Without delay the Administrator or designee shall initiate and complete a thorough investigation into the allegation of abuse. This includes interviews of the alleged victim, alleged perpetrator, witnesses, residents, and staff as indicated.
This was not done. The investigation was not initiated by E#1 until 7:00A.M. on 11/29/01. There is no documentation that R#2 was ever examined by a physician. E#4 and E#5 wrote an account of their observations (per interview on 12/5/01) but E#1 refused to let surveyor view the documents.
The facility's policy further states:
6. An incident report will be completed and appropriate documentation placed in the resident's record.
This was not done. Documentation was not entered into R#1's and R#2's records until 18 hours later per instructions given by E#1 to E#2 and E#3.