New Beginnings Care Centre
Facility I.D. Number: 0035642
Date of Survey: 01/09/2003
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 andpersonal care shall be provided to each resident to meet the total nursing
and personal care needs of the resident.
The DON shall supervise and oversee the nursing services of the facility, including:
Overseeing the comprehensive assessment of the residents needs, which include medically defined conditions and medical 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.
Developing 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.
Supervising and overseeing in-service education, embracing orientation, skill training, and on-going education for all personnel and overseeing all aspects of resident care and programming. The educational program shall include training and practice in activities and restorative/rehabilitative nursing techniques through out-of-facility or in-facility training programs. This person may conduct these programs personally or see that they are carried out.
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 interview and record review the facility failed to:
1) have supervisory staff knowledgeable on the facility's policy and procedure on abuse prevention
2) have staff immediately report allegations of sexual abuse to the administrator,
3) conduct an investigation of allegations of sexual abuse when they were reported on approximately
October 18, 2002, October 22, 2002, and in late November, 2002; and
4) assess, care plan and monitor R1 and R2's activities once allegations of abuse/sexual activity were reported.
The findings include:
Z1 went to R1's room. He was in bed covered up. R2 was in his own bathroom. R2's roommate was in R2's room so Z1 waited one half-hour to 45 minutes before trying to talk to R2. Z1 stated she monitored the residents in the meantime. Z1 stated then R2 came out to the nurses station and then R2 went to bed at approximately 10:00 P.M.. When asked if she had been informed of the facility's abuse prevention policy before or at the time of working at the facility on 12/21/02, Z1 replied that she had not been told of the facility's policy.
E3 was interviewed on 12/23/02, at 12:10 P.M.. E3 stated at approximately 7:00-7:30 P.M. on 12/21/02, she saw R1 and R2 walking down the hallway going towards their rooms. A short while later E3 walked into R1's room and saw R1 bent forward in a hospital gown with nothing else on. R1 was making funny faces. R2 was observed standing behind R1 with his pants unzipped and his penis hanging out. At that point E3 told R2 he had to get out of R1's room. R2 turned to zip up his pants. R2 did not leave immediately, so E3 went to get Z1. When E3 left to find Z1, E3 saw R2 leaving R1's room. E3 said she informed Z1 that she had to call E2.
E2 was interviewed on 12/23/02, at 11:10 A.M.. E2 stated he was informed of the alleged incident when he came in at 6:30 A.M. on 12/22/02. E2 stated that R2 is alert and oriented all of the time. R2 has never been know to be sexually promiscuous. R2 appears to be close friends with R1. R1 seeks R2 out by touching. R2 doesn't have any other close friends in the facility. On 12/26/02, E2 was asked if he was aware of any other incidents between R1 and R2. He stated that he was aware that a housekeeper saw R1 and R2 in the bathroom and R2 had his hands on R1's hips. E2 also said that "about 5 months ago" an aide saw R1 and R2 together and reported it to the DON at the time. E2 (current DON) cannot find the report for that incident.
E8 (CNA) was interviewed on 12/26/02, at 12:25 P.M.. E8 was asked if she had ever seen R1 and R2 alone together. E8 stated that about one week before the previous DON left (last work date was 10/25/02) she found R1 and R2 in R1's bathroom. R1 had on only a hospital gown. R2 was standing really close behind R1 tying the gown. This occurred at approximately 8:30 P.M.. E8 stated she told the previous DON , who was working the floor that night, and she "freaked". E8 stated she observed a lot of touching between the two residents and R1 seemed to be the one who initiated it. E8 stated that R2 sometimes seemed sick of being around R1, asking E8, "You want to adopt this big kid?"
An interview with Z2 (police detective) was done by phone on 01/06/03, at 11:17 A.M.. Z2 was at the hospital and spoke with the physician who examined R1 on 12/22/02. The physician told Z2 that he did not see any old scarring or any new tearing in the anal area. The physician also said that it is possible that the two males R1 and R2 were getting ready to do something. A sexual assault kit was done but has not been processed. The local police are waiting to hear what the State's Attorney is going to do about this case.
A review of the Emergency Room examination report on 12/22/02 indicates," no evidence of trauma. A lot of stool around and in anal opening".
Z4 (R1's Power of Attorney) was interviewed on 01/02/03, at 11:18 A.M., by phone about the incident on 12/21/02. Z4 states that she is in the process of getting guardianship for R1. Z4 said this was the first time that the facility had called about this incident and that E2 told her it had been going on for "about 5 months". Z4 was concerned that she was not notified of the incident on 12/21/02, until 8:00 A.M. on 12/22/02. Z4 stated that she is the one who wanted a sexual assault kit done on R1. Z4 stated that R1 lived at home with his parents all of his life until he was admitted to another facility on 04/26/02. He was transferred to the current facility on 05/20/02, along with his mother.
Review of R1's nurses notes dated 10/22/02 state,"A CNA observed this Res (resident) et (and) another Res in his B/R this resident was getting his buttocks rubbed by another Res". This nurses note was written by E13. On 12/23/02, at 1:06 P.M., E13 was interviewed. E13 was asked if he was aware of any occasions when R1 and R2 were found alone together. E13 replied that, "The CNAs came to me in October or November and reported a couple of times. They reported 'mutual masturbation' involving R2 and R1". Both times they were caught in R1's room, once by a CNA and once by laundry staff at about 9:00 A.M. in the morning. The CNA reported to E13 that R1 and R2's backs were to the door. They were standing together and the CNA heard "you naughty boy". The other time when the laundry staff reported R1 and R2's behavior to him, he went to look and both residents were coming down the hall. E13 said he doesn't think he made any notes of this incident. E13 looked in R1's record and did not find any notes about the incident.
E5 (Laundry staff) was interviewed on 12/23/02, at 12:20 P.M.. E5 was asked if she had ever seen R1 and R2 alone together. E5 said that sometime in November (after Thanksgiving) early in the morning around 6:30 - 7:00 A.M., she was picking up laundry. She came to R1's room and R1 was in his closet. R2 was behind him. It looked like R2 was "humping" R1. E5 left the room and went to tell the nurse (E13 - LPN). R2 came out of R1's room right after E5 had been in there. E13 told E5 to report it to E2.
3. R1 was interviewed on 12/26/02, at 11:15 A.M.. R1 was asked if he had any problem with men in the facility. R1 replied, "no". When asked if anyone had tried to insert anything in his behind, R1 changed the subject. The resident changed the subject each time a question of a sexual nature was asked. R1 did not stay focused on the subject being discussed and he would respond to the surveyor about what kind of car the surveyor drove.
From a review of Psychological test results dated 07/10/02, R1 was confirmed as having a diagnosis of Severe Mental Retardation. R1 has a verbal reasoning comprehension of three years, 10 months; Abstract/Visual Reasoning Pattern Analysis of age two years, two months; Quantitative Reasoning age four years; Short-Term Memory for Sentences three years, two months; a Receptive Vocabulary age two years 6 months, and an overall age equivalent of five years.
A review of R1's Minimum Data Set (MDS) of 06/30/02, reveals short term memory loss and moderately impaired decision making skills. He is easily distracted, has periods of restlessness and his mental function varies over the course of the day. He asks repetitive questions and makes repeated verbalizations. R1 needs supervision and set up for dressing and limited assistance and set up for personal hygiene. He needs some or all Activities of Daily Living (ADLs) broken down into sub tasks to complete them. The Quarterly MDS of
09/05/02, and 12/03/02 include the same assessments as 06/03/02, and also identify R1 as displaying wandering, verbally abusive behavior symptoms, and socially inappropriate/disruptive behavior symptoms.
The Care Plan dated 12/03/02, for R1 identifies a problem of "Disruptive and Loud", yells out when impatient and insists on things happening "now". Another problem dated 09/12/02, resident hit a staff member two (2x) times, gets upset easily. Touches inappropriately. The care plan does not define what R1's "inappropriate touching" is.
A review of R1's care plan dated 9/12/02 and 12/3/02, under the problem of Touches Inappropriately the approaches are: 1) Inform him that this is inappropriate, 2) Prompt when he walks up to you with intents to touch, 3) Hold hands up in front of you and prompt not to touch, 4) Praise when he comes up and doesn't touch. There is nothing on R1's care plan that addresses R1 seeking out R2 or of any plan to monitor the behavior between R1 and R2 after the October and November episodes.
A review of the Determination of Developmental Disability & Associated Treatment Needs done by a local Pre Assessment Screening (PAS) agency on 04/26/02, contained the following information. Under Part II - Determination of Need for Specialized Services is checked yes for R1. Also listed are justifications. They are: R1 has limited abilities to deal with emergency situations. He needs training in the area of Safety Skills, R1 needs prompts and reminders to complete daily living activities, R1 tends to rely on others to initiate activities, and R1 has been sheltered his whole life and is vulnerable to exploitation.
4. R2's Diagnoses including Trans Ischemic Attack (TIA), Parkinson's, Hypertension, Diabetes - Type II, according to the December 2002 Physician's Order Sheet. R2's full admission MDS dated 03/27/02, assesses him as having no short-term or long-term memory problems and modified independence in daily decision making - in new situations only. R2 was assessed as having no indicators of depression and no behavior symptoms and is independent in ambulation with no loss of Range of Motion. A psychiatric evaluation completed on 04/10/02 states he has no past psychiatric treatment. His diagnosis from this evaluation under Axis II, Personality Disorder is, probably type A. A mini-mental assessment was completed on 09/19/02. R2 scored 29 out of a possible 30. R2's care plan with dates of 03/27/02, 06/25/02, and 12/25/02 was reviewed. It contained no plans to counsel or monitor R2 in relation to his relationship with R1.
R2 was interviewed on 12/26/02, at 12:00 P.M., R2 was asked what happened on 12/21/02. R2 stated, "I was helping another resident put his gown on. All I was doing was helping him tie the back of the gown. A housekeeper saw this and said that I had my penis out". When asked if his penis was out, R2 replied, "No". When R2 was asked about the 10/22/02 incident documented in the nurses notes about being found rubbing another residents buttocks, R2 had no recollection of that incident. R2 was asked if he ties anyone else's hospital gown and he replied, "No".
5. A review of the facility's policy and procedure on Abuse under item IV Internal reporting Requirements and Identification of Allegations, Paragraph 4 states, "Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation." The fifth paragraph, second sentence states, "Upon report of such occurrences the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee." Under item V., "residents who allegedly mistreated another resident will be removed from contact with that resident during the course of the investigation."