THE ARC OF JACKSONVILLE, LTC
Facility I.D. Number 0032930
Date of Survey:10/30/01
Notice of Violation:01/29/02
Annual Licensure and Complaint Investigation
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each residents comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
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 interviews, record reviews, and final incident investigation reports, the facility failed to prevent resident to resident abuse from occurring in that R6 was allowed to continue with inappropriate sexual behaviors without appropriate intervention, R3 was not protected from sexual behaviors from other male residents and R2 was allowed to continue with sexually inappropriate and aggressive behaviors toward others and was the recipient of abuse from other residents. The facility failed to report to the appropriate authorities in a timely manner and failed to take action to prevent further such incidents to residents.
1. R6 is a 59 year old male with diagnoses that include schizo affective disorder, history of CVA (cerebrovascular accident), water intoxication with hyponatremia, sexual preoccupation, para phila-pedaphile, and others.
R6 was readmitted to this facility 7/12/01.
R6 was receiving "Provera 20 mg." daily (Provera is a synthetic progestin given, in this case, to decrease sexual urges) prior to his readmission. This continued to be given on a daily basis after R6's readmission R6's "Psychiatric Progress Note" dated 8/7/01 reveals under "Current Symptoms" that "Nsg (nursing) staff reports pt is sexually aggressive - redirects poorly - tries to kiss staff & residents. Some female residents are accepting of this behavior."
Review of R6's medical record indicated that a call was placed to Z2 (psychiatrist) office on 7/20/01 regarding R6's sexual behaviors. Z2 ordered that a testosterone level be done. R6's "Provera" was increased to 40 mg. on 7/20/01 due to "being friendly with women".
R6's assessment dated 07/25/01 indicates that R6 has no long or short term memory problem and is scored as a "2" for cognitive skills for daily decision making. This means that R6 is "Moderately impaired". This same assessment reflected no behavioral symptoms.
R6's "Sexuality Assessment" dated 7/18/01 indicated that R6 "Pats and Kisses".
R6's care plan of 7/19/01 reflects that R6 was to be enrolled in a "Sexuality Group" as one of the approaches to be taken for this behavior.
The goal for this behavior was "To reduce the number of incidents with the eventual elimination of all episodes [of sexually inappropriate behavior].
The following events took place from R6's admission on 7/12/01 through 8/15/01. R6's nurse's notes dated 7/15/01 state "...has female girlfriend already..." Further review revealed that R6 had behaviors of grabbing a nurse's buttocks, making sexual innuendoes to staff, wanting to kiss nurse, unzipping fly [of his pants], singing about "sex and kissing", hugging and kissing female staff and female and male residents, stating to a CNA (certified nurse's aid) "I'd like to have sex with you but I am too old and I can't ".
On 8/15/01, Z2 was notified and increased R6's "Provera" to 30 mg. R6 was already receiving 40 mg daily of this medication. (Note that another facility nurse noted this error; R6 was NOT decreased to the 30 mg. dosage).
Review of R6's "Behavior Tracking for Sexual Inappropriateness" identified that R6 had 67 recorded episodes in September 2001. These occurrences included R6 kissing different female and male residents and offering to pay a CNA $5.00 to undress him for bed.
On 9/12/01, Z2 was notified of R6's "sexual behaviors". Z2 ordered "Climara Patch" 0.05 mg/day be added to R6's medication regime. The intent would be for this medication to decrease R6's libido. R6 continued to receive "Provera 40 mg." on a daily basis.
R6 had 10 incidences of sexually inappropriate behaviors on the evening shift 9/27/01. ( Surveyor was unable to determine how many more incidences occurred for the remainder of September as the tracking sheets were not completed.)
Z2 increased the dosage of R6's "Climara Patch" to 0.1mg/day on 9/27/01.
Review of R6's October 2001 tracking sheet for inappropriate sexual behaviors revealed that between October 1- October 25 R6 had 5 incidences on the day shift and 19 on the evening shift.
The "Sexuality Program" that R6 was to have started on July 17, 2001 was NOT implemented until October 22, 2001.
Interview of R3 on 10/10/01 revealed that R6 grabbed R3 between the legs (crotch area) sometime on October 6 or October 7, 2001. R3 stated that she did report this occurrence to staff.
R6 was interviewed on 10/23/01. R6 was asked if "it was all right to kiss a woman or to touch up between her legs?" R6 responded with "Yes, they all do it, if they're boyfriend and girlfriend."
R6 was asked if he had ever been told to not sit on the couch; he indicated that he is not supposed to sit on the couch, but evaded answering why. When asked why he stated "I don't know why" and "They don't want me to".
The facility has no indicators as to the identity of each resident that R6 has approached and/or behaved inappropriately with.
2.) R3 is a 28 year old female with diagnoses that include Schizophrenia and Alcoholism.
Interview of R3 on 10/10/01 revealed that a few days before this interview, R3 was walking down the hall on the left side. R2 was coming towards R3, R2 was on the right side of the hall. As R2 walked past R3, R2 reached out and grabbed R3's right breast and then let it go. R2 then turned around, looked at R3 and smiled.
R3 stated that she had been told that R2 does tend to fight and hit and pat others on the butt.
R3 observed R4 punch R2 in the chest and slam him up against the wall on about 10/08/01. This was because R2 was either looking at or trying to take an ashtray away from R4.
R3 indicated that staff just made sure that R4 did not get close to R2 for the rest of the evening.
R3 stated that also on the weekend prior to this interview that "this guy (identified as R6) grabbed me between the legs". R3 was asked to show and/or tell how she was grabbed. R3 indicated that she was sitting on the couch with her legs propped up on the couch. Then R6 touched her outer thigh. R3 stated that she told R6 to stop, but then he just reached in and touched her crotch area. (R6 has been previously discussed in Example 1).
It is unknown why steps were not taken to protect R3 from the known behaviors R6 was known to exhibit.
3.) R2's problematic behaviors are chronicled below:
R2 was admitted to the facility on 02/19/01 with diagnoses of hypertension, depression- depressive disorder, schizophrenia, cardiac murmur, psychosis, and thiamine deficiency.
History & Physical dated 02/09/2001 by Z4 (M.D.) reveals "..... apparently gotten more agitated the last month or two where his wife had not been able to handle him and he was getting increasingly aggressive, was toting gun to the head and also was hoarding knives under his bed. As situation was rapidly worsening his wife called the police who took him to the...emergency room where he was evaluated and then this hospitalization was initiated."
On 02/09/2001, Z5 (LSW) provided a Psychiatric Social Service Assessment that documents "...(R2 as been becoming increasingly confused, disoriented and threatening to his wife...had been hiding knives, she thinks, with certain intent to kill himself or her....he had held a gun up to his head and she thought he was going to shoot himself or her... described by (Z6) (his friend) as being out of control for several months...he had been in a brooding mood. He was mad all the time and that she had found two knives on this date hidden under a mattress..and that (R2's wife) is in great fear for her own safety if he does return (home) at this time. "
Z4's consultation notes of 02/12/01 "...in the last month the patient (R2) has been out of control,
threatening to shoot himself on three different occasions or picking up a knife and threatening to kill someone. The patient took care of his wife for some years, but now the wife is afraid of him."
The following events occurred between R2's admission to the facility on 02/19/01 and 9/22/01, when he was admitted to the hospital:
Two (2) episodes each, of hitting residents, sexual behavior toward residents and sexual behavior toward staff.
Seven (7) episodes of hitting staff.
Eight (8) episodes of aggression to residents.
Nine (9) episodes of aggression to staff.
Five (5) episodes of being in other residents rooms.
One (1) episode of violent behavior.
On 03/08/01, R2 was readmitted to the hospital for "Increasingly violent-PRN (as needed) thorazine ineffective."
Psychiatric Progress notes completed 05/29/01 (by Z8 )( R.N.) and signed and dated by Z2 on 06/11/01) document "Staff reports frequent incidents involving increased agitation, hitting staff, peers, wandering around the facility, pushing on doors, entering rooms of other residents. Nsg. (nursing) notes indicate 2 reports of sexual advances directed at CNA ...one fall documented on 04/08/01 without injury. Frequent reports in nsg. notes documenting pt. (patient) hitting staff and peers, occurring on 04/15/01, 04/16/01 and 05/27/01. Recent report of injury to head requiring stitches. Details of events not specific (from 05/25/01) but pt. was in another residents room at time of injury. Pt. given thorazine following behaviors."
History and Physical of 09/13/2001 by Z2 notes "...(R2) has also become more aggressive. He has done things in the past such as hoarding knives under his bed and holding a gun to his head. His wife had become more concerned about his behavior and fearful of her safety, and brought him to (the hospital)...evaluated...then discharged to (this facility)....(R2) became increasingly agitated at the nursing home. He was flinging things at the nurses and pacing the hallways, trying the doors and picked up objects and threw them at people. P.R.N. Thorazine did not help ....(R2) admitted to (the hospital, again)...Despite (changing R2s' meds) ...he still has periods when he has become agitated. Over the last week he has hit or pushed several residents. On the day of admission he pushed another resident to the floor. Nursing home called and wanted him re- evaluated due to his behaviors......SOCIAL HISTORY:....he (R2) was arrested once for beating his wife. MENTAL EVALUATION EXAMINATION: ...He (R2) becomes very angry at myself (Z2 M.D.) when I try to ask him questions, and he states, Just shut your a--hole. He then brings up his arm as if to hit me."
09/27/01 R2 was readmitted to the facility and his nurses' notes continue:
10/01/01 R2 attempted to take R1's silverware away from her at breakfast time, R1 wouldn't give them up so R2 hit R1 in the nose with his fist. Thorazine 50 mg. given by mouth.
"10/02/01 11A increased behaviors of hitting staff...."
"l0/ 03/01 9:55p.m. Resident grabbed a female residents breast (R3)..."
"10/05/01 10:50a.m. Res attempted to hit another res when staff intervened....10:05p.m. Resident aggressive on this shift tried to hit CNA's and nurse PRN IM thorazine given....."
"10/07/01 10:25p.m. Resident aggressive with nurse and CNA's on this shift PRN thorazine given..."
"10/08/01 7:30 p.m. Resident (R2) kept trying to take ashtray from another resident (R4) and (R2) was pushed against wall by (R4)..."
The incident of sexual abuse to R3 on 10/03/01 was not investigated by the facility as of the afternoon of 10/15/01 (12 days later), and the incident of physical abuse to R2 by R4 on 10/08/01 was not investigated as of 10/15/01 2:00p.m., (7 days later).
R2's ACTIVE TREATMENT /PSYCHO-SOCIAL CARE PLAN last dated 09/22/01 does not list R2's Problems/Needs and Approaches of sexual and physical abuse to residents/or staff, however does include R2's " wandering- entering others rooms....where by problem has developed with he and other residents in a physical altercation...(goal of) To reduce the number of episodes of wandering."
On 10/10/01 E1 provided surveyor an updated ACTIVE TREATMENT/PSYCHOSOCIAL CARE PLAN that was written 10/09/01 (after surveyor started investigation) that states" ....Inappropriate sexual behaviors. Touching females breasts, placing hand between the legs and attempting to kiss females.
E1 also provided surveyor MOOD & BEHAVIOR BEING TRACKED form started on 10/10/01 (after surveyor started investigation) that documents "Inappropriate sexual behaviors (Touching females breasts, placing hands between legs and attempting to kiss females)."
MOOD & BEHAVIOR BEING TRACKED Form for September 2001 for wandering-entering other resident rooms and for resisting care/ combative (actions toward CNA'S) are blank for all three shifts from 09/27/01 (the day of R2's readmission to the facility) through 09/30/01.
According to E1 and E7, R2 had been on 15 minute checks since at least May 2001, however these forms are not completed for the months of May, June, July, August, September and October. The staff (including E1 and E7) could not find safety checks forms for each day of the above listed months.
R2's current minimum data set (MDS) of 08/13/01 does not have socially inappropriate/ disruptive behavioral symptoms (...sexual behavior...) triggered. Quarterly MDS of 05/22/01 does not trigger physically abusive behavior symptoms or socially inappropriate/disruptive behavioral symptoms.
Interview with staff (E14, E15, E10, E11, E12, E13) reveal that in the past they have done 15 minute checks, but have not done so recently.
Interview with E6 verified that the 15 minute safety check sheets cannot be located, however she does believe that the staff were monitoring and watching R2. Interview with Z2 (M.D.) on 10/15/01 at 2:15p.m. reveals that Z2 would have liked to have been notified of R2's behaviors and PRN thorazine 50mg. given by mouth on 10/02/01, 10/03/01, 10/04/01, 10/05/01, and given IM on 10/07/01 and on 10/09/01. Z2 stated, " If I would have been notified sooner of R2's behaviors and use of thorazine PRN, I would have been able to determine that the medication wasn't working and I would have sent R2 to the hospital sooner. Instead facility staff sought admission of R2 to the hospital after surveyor had begun investigation."
4.) The facility has identified as of 10/18/01, 18 of 71 residents currently residing in this facility are in a "Sexuality Group." However, no group was started until 10/22/01.
The start date of this group is months after the need was identified and care plan indicated that several individuals were already participating in such. Identified residents include at least: R4 (previously discussed), R6 (previously discussed), R23 (for attempting to kiss female staff members; to have started this program 9/22/01), R26 (for delusions about being sexually assaulted; to have started this program 7/8/01), R27 (for verbalizations about sex/bestiality; to have started this program 9/22/01), R57 (for offer/solicitation to perform sexual favors; to have started this program 7/24/01), R75 (for sexual inappropriateness with staff; to have started this program 7/19/01).
5.) Interviews of CNA staff on 10/30/01 reveal that they have not been trained in any additional methods to intervene in inappropriate sexual behaviors. They continue to tell the resident/s to "stop" and/or to tell them that what they're doing is not appropriate. They have had additional training on documentation and reporting to the nurses incidents of inappropriate behaviors.