ALDEN PARK STRATHMOOR
Facility I.D. Number0044909
Date of Survey:08/06/02
Notice of Violation:11/26/02
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.
The DON shall oversee the nursing services of the facility including:
Overseeing the comprehensive assessment of the residents needs, which include medically defined conditions and medial functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
Planning an up-to-date resident care plan for each resident based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
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 CONDITON 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 interview, the facility failed to keep 4 female residents (R2, R3, R4, R5) residing on the dementia unit free from sexual abuse from June 18, 2002 to July 21, 2002 by not:
a) Monitoring the whereabouts of a resident (R1) with known sexual behaviors,
b) Following recommendations of Dementia Unit Coordinator to not place an alert male resident on the Dementia Unit ,
c) Having a plan of care addressing the residents sexual aggression,
d) Having a plan of care with approaches on how staff could protect the dementia residents.
The findings include,
R1 admission record dated 06/13/02 revealed the following diagnoses Hypertension, Depression
R1's Cognitive Loss / Dementia Minimum Data Set RAP (Resident Assessment Protocol) Module dated 06/26/02 revealed that there is not a decline in R1's cognitive state and R1's cognition was not affected secondary to a diagnosis of dementia.
R1's Psychosocial and Social Service Assessment dated 06/13/02 revealed, R1 attempts to make wise decisions, retain independence and has strong verbal communication skills.
R1's history and physical dated 07/12/02 revealed that R1 is alert and oriented x 1.
During review of R1's Social Service notes E6 charted;
06/18/02 "Resident was found in his bed with another female resident (R4) and he was fondling her."
06/24/02 "At 1400 resident (R1) was observed bringing a female (R3) resident into his room."
07/02/02 "Resident (R1) was found coaxing another female (R5) into his room."
Review of Facility Incident Report for R1 dated 07/20/02 (there was no time that incident occurred on the incident report) revealed, "This resident was seen leaving a shower stall approximately 5 minutes later Staff found a naked female resident (R2) in the shower room extremely agitated." The incident report revealed R1 was sent to the hospital emergency room at 1930 and returned to the facility on 07/21/02 at 0200.
Review of the Facility incident report dated 07/20/02 at 1615 revealed, "This resident (R2) found in shower stall naked with male resident (R1). Following this incident resident (R2) yelling ?HELP ME HELP ME He raped me."The incident report also revealed that R2 was sent to the hospital at 2030 on 07/20/02 and returned to the facility at 0230 on 07/21/02.
Review of the nurses notes for R2 dated 07/20/02 revealed E11 charted, "E2 is handling the situation." E2 stated, "Don't send the resident out until I tell you." at 2025 E2 stated," Go ahead and send the resident out to the Emergency room for a pelvic exam."
On 07/25/02 at 1020 E8 was interviewed on the dementia unit. E8 stated, "E12 and I were the only aides working the pm shift. I started to work at 1400. R1 and R2 were wandering in the hallway. R1 was on an informal watch because of sexual behaviors. R1 tried to get women alone and have sex with them. He knew what he was doing he would try to coax them into empty rooms. On 07/20/02 at about 1600 E12 and I (E8) were going to start our showers. We had our first resident and were headed for the shower room when we saw R1 peeping out of the shower room door. R1 came out of the shower room and headed toward the dementia unit door. E12 and I (E8) entered the shower room and turned on the lights and there was R2 standing naked in the shower room. E12 said since she (R2) is already naked lets give her a shower. R2 had urinated on her legs so E12 was washing her and R2 started crying and getting very upset saying don't wash me, that man raped me. R2 was calling for her mother and saying don't let that man hurt us. We (E8 and E12) told the nurse from day shift what R2 had said."
During a telephone interview on 07/25/02 at 1040 E12 was interviewed and verified E8's account of the events on 07/20/02. E12 stated, "It was very unusual for R2 to fight during her showers because she enjoyed them."
E10 was interviewed on 07/25/02 at 1020 on the dementia unit, E10 stated, "R1 wasn't like the other residents you could talk to him and he knew what you were saying. He knew what facility he was in because we would ask him and he would tell us. E6 had recommended we place him (R1)on an informal watch. That means keep an eye on him. We have 27 demented residents on this unit and we can't always know where everyone is all the time. It gets hectic at meal times, when we give showers, and when we're trying to get every one in bed. There are only two aides scheduled on this wing for days and pms."
E6 was interviewed on 07/25/02 at 0935 in the conference room. E6 stated "After the incident on 06/18/02 E7 was fully aware of the sexual incident that occurred that day. I had told E7 that R1 was not appropriate for the dementia unit. I told staff they had to monitor R2's movement in the unit. There are women on the unit who like men (R2, R3, R4, R5) nothing sexual just hold hands and smile at any man who comes on the unit and these are the women he would target and coax into his room."
Review of R1's social service note dated 07/22/02 revealed, "E14 spoke with R1 about his behavior on Saturday. R1 stated, "He knew it was inappropriate but has sex for his own pleasure. R1 was unsure if he would do it again."
Review of the Facility's Petition for Involuntary / Judicial Admission for R1 dated 07/22/02 revealed that on 07/21/02 R1 had propositioned R6 and coaxed her into his room.
R1's care plan dated 6/13/02 was reviewed and identified sexual behaviors were not addressed.
R1 was involuntarily admitted to the phychiatric unit at a hospital at 1700 on 07/22/02.
Review of the Accumulative Diagnoses Records for R3, R4, R5 revealed they all had diagnoses of Dementia.