River Bluff Cahokia Nursing & Rehabilitation
Facility I.D. Number: 0045005
Date of Survey: 05/29/2003
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.
Objective observations of changes in a residents condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the residents medical record.
A FACILITY EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR.
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 REQUIREMENTS are not met as evidenced by:
Based on record review and interviews the facility failed to protect residents by assuring that residents had an environment that was free from sexual abuse. The facility had knowledge of a resident (R3) with inappropriate sexual behavior toward other residents. The facility had not consistently identified the victims, had not conducted thorough investigations, and had not implemented preventive measures to protect the residents from actual and potential sexual abuse. There were two incidents of actual harm with two identified sample residents (R1, R2).
A Behavior Report dated 10/28/02, referring to an incident occurring on 10/18/02, identify consequences of R3's behavior to be "... Potential Injury to other residents....", and to change the current care plan to include increased visual supervision.
On 10/21/02, R3's Care Plan was modified by adding "Altered sexuality pattern, inappropriate sexual advances to female peers of younger age, i.e., rubbing back, legs, attempting to hold female residents hands." Entry on the same document indicate the facility set the goals as decreasing such activities to "... less than 1x /day thru next quarter ...." Additionally, the Approaches section identified several areas requiring staff awareness and monitoring for such behaviors as needed to achieve the goals identified.
A review of nurses notes dated 10/27/02, at 11:30a.m. indicates R3's wife (Z5) approached E4 concerning R3's increased sexual desires. According to the notes, R3 had become upset after Z5 refused to have sex with R3 in his room. According to the nurses notes dated 10/27/02, at 11:30a.m., Z3 (Physician) was contacted concerning the incident. Physician Order Sheet indicates Z3 ordered Provera 10mg/po/qd. to be added to R3's medications.
Examination of R3's Care Plan showed that it was reviewed again on 11/07/02, with the same problems, goals and approaches being identified as had been on the original Care Plan dated 10/21/02.
Nurses Notes, from R3's medical records dated 01/29/03 provide an entry at 6:30p.m. which documents R3 and R2 being found in R3's room lying on his bed with both residents having their pants down. According to the following entry at 7:15p.m., R3 and R2 were found in R2's room both residents sitting on R2's bed holding hands. According to the same Nurse Notes, R3 was placed on 15-minute monitoring at 10:00p.m. that evening. A review of R2's Nurses Notes provided no entry concerning the encounters between R3 and R2 or measures implemented to insure no further incidents involving R2.
During an interview on 05/06/03 with E6, LPN (Licensed Practical Nurse) stated she had found R3 and R2 in R3's room in January, but did remember making a written report either in the Nurses Notes or to facility administration. E6 stated she informed the nurse working on R3's hall, but had not been asked about the incident by facility administration.
According to facility's 15/30 Minute Monitoring Sheet(s) dated 01/29-01/31/03, R3 was monitored by nursing staff during that time. During an interview with E4, E4 stated when a resident is placed on a 15/30 minute monitoring check the monitoring period will end in 72 hours unless something else occurs.
During interviews with CNAs (Certified Nursing Assistants) E13, E16, E17 and E18 on 05/06/03, E13,16, and 18 all indicated they have worked on both the male and female halls in the facility. Each of them indicated they were not aware of previous incidents involving R3 and allegations of inappropriate sexual behaviors. Additionally E13, 16, 17 and 18 stated they had not been advised to watch for any particular behaviors being displayed by R3.
During an interview on 04/30/03 with E2, Registered Nurse Consultant, E2 stated there had been no incident report or investigation done concerning the 01/29/03 incident involving R3 and R2 because the facility felt both residents were consensual participants. A review of R2's assessment dated 01/22/03 indicated R2 had moderate cognitive impairment, poor decisions, cues/supervision required as listed in section B4.
A review of R3's Monthly Summary sheet dated 02/13/03, signed by E6, noted under: "Goals: 1. Will demonstrate a decrease in inappropriate expressing of sexual behavior to less than once a day thru next quarter. (had increase in medication for this behavior) (not met) ...."
Review of R3's Care Plan showed a third review dated 01/30/03, of the Plan by the facility was completed and the same problems, goal(s) and approaches were identified. Additionally, the sheet indicates an increase in Provera on 02/04/03, to 20mg QD. Visual checks were again indicated as one of the approaches to achieve the identified goal of decreased inappropriate sexual advances.
During the interview with E4, E4 states R3 was transferred to a local hospital on 04/25/03, after R3 had a physical encounter with E4 and another staff member. According to E4, R3 had become angry and physically aggressive during a conversation in her office.
During an interview on 04/30/03, with E7, LPN, E7 stated she was working the afternoon shift on 04/26/03, when R1 came to E7 and asked if R3 was in jail. E7 asked why R1 would think that R3 was in jail. According to E7, R1 said R3 had forced her into R3's room to have sex with him. R1 said that R3 had hurt her and that R1 was afraid that R3's wife would also hurt her. R1 again said that R3 had forced her into the room to have sex but that R1 did not hurt now. E7 said that R1 kept repeating her statement and E7 noticed a change in R1 behaviors. E7 stated R1 "... sits alone now, acts scared and shakes...." E7 stated she did not report the incident or make notes in either residents medical file because she did not believe R1 at the time but after a telephone call on 05/27/03, E7 stated she then believed the incident occurred.
According to the facility's investigation report, E7 reported that she contacted E3 (Care Plan Coordinator) on 04/27/03, at approximately 11:30p.m. after she had been told of the telephone call by R3 to E6 earlier in the evening.
On 05/06/03 at 4:15 p.m. during an interview with E6, E6 stated she had received a telephone call at approximately 7:00p.m. 04/27/03, from a male caller. According to E6, the caller was asking to speak to R1 and identifying himself as Z8. The caller, after being challenged by E6 as to his real identity, admitted to being R3 and that he was calling to apologize to R1 for having sex with R1.
According to E6, R3 stated he and R1 had several sexual encounters during the past four or five days and that "It was my fault, not (R1's)." E6 said that she reported the telephone call to R3's nurse, E7, shortly after she received the call. According to E6, E7 at that time mentioned the conversation E7 had the previous day with R1 and commented to E6 that "... maybe R1 was telling the truth...."
On 05/13/03 during an interview with R3 outside the facility, R3 stated he had called the nursing home to talk with R1. R3 said he tried to disguise his voice but the nurse recognized his voice and would not let him talk with R1. R3 said he told the nurse that he had sex with R1 and he was calling to apologize and tell R1 she was a good person.
R3 said that E4 had spoken to him about having sex with R1 prior to R3 being transferred to the hospital on 04/25/03. According to R3, E4 questioned him saying "... you're having sex with R1..." and that R1 had a comprehension level of a 14- year-old. R3 stated he felt that the problems he was experiencing since the first of the year was being caused by the increased medications. R3 stated he had tried to speak to E4 about his problems but E4 would "... tell me what she wanted to say and then leave, not letting me say anything ...."
On 05/13/03 during an interview with R1, R1 stated she had sex with R3 but could not remember when or where. R1 said that her mother had told her what she and R3 had done was bad and that she should not be doing those things with anyone. R1 said that she did not like to talk about it because it makes her feel bad.
A review of R1's MDS, dated 01/28/03 shows R1 to have moderate cognitive impairment for decision making abilities. R1's current Care Plan indicates R1 to be at risk for abuse and neglect with, "...poor judgement skills, easily exploited...."
On 05/13/03 during an interview with Z3, Z3 stated that he had prescribed Provera due to sexual incidents involving R3. According to Z3, on 04/28/03, R3 told Z3 about the sexual incidents involving R1 but refused to identify the female resident. Z3 confirmed R3's ability to be interviewed and understand the ramifications of his actions. Specifically Z3 stated, "R3 could very well be out in the community, but that R1 could not be by herself."