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Based on observation, interview, record review, and review of the facility's abuse policy, it was determined the facility failed to protect residents from abuse for one (1) of ten (10) sampled patients. Patient #2. The facility failed to report an allegation of sexual abuse to the appropriate state agency. Facility staff witnessed sexual abuse against Patient #2. The facility immediately removed the alleged perpetrator, called the local police, and began an internal investigation. However, the facility failed to report the allegation of sexual abuse to the appropriate State Agency (SA) according to state law KSR 209.030.

The findings include:

Review of the facility's Abuse Policy, dated February 2014, revealed the facility supported a patient's right to receive care in a safe setting and would act to protect vulnerable patients. The facility would respond to allegations of abuse, including prompt reporting to facility leaders and applicable state agencies. The facility would investigate allegations of abuse promptly in accordance with state law. The facility referenced state law KRS 209.030 as guidelines for reporting abuse. The Abuse Policy defined a dependent adult to be any person between ages of eighteen (18) and sixty-four (64) who had physical or mental limitations which restricted his/her ability to carry out normal activities or protect his/her rights.

Review of KRS 209.030, current date of 06/01/14, revealed an oral or written report shall be made immediately to the cabinet upon knowledge of suspected abuse, neglect, or exploitation of an adult.

Interview with the facility's Chief Executive Officer (CEO) and Chief Clinical Officer (CCO), on 02/09/16 at 9:42 AM, revealed License Practical Nurse (LPN) #1 observed the alleged perpetrator naked, on top of Patient #2, attempting to have sexual intercourse on 02/05/16. The nurse called for help and the perpetrator was removed from the patient's room. The local police was called and the alleged perpetrator was held in another room for questioning. The police arrested the alleged perpetrator and a rape kit was performed. They both stated the patient could not give consent, because the patient was not oriented to person, place, and time. The CEO stated the staff informed her the patient appeared to be afraid through observation of non-verbal gestures and body language. The patient desaturated (decrease in the oxygen level in the blood) and a rapid response (a significant change in the patient condition, used to avoid a code) was called after the incident. She stated the patient's physician was called and ordered a toxicology screen (a test for drugs and other chemicals) because the facility did not know if the alleged perpetrator had drugged the patient or not. The toxicology test results was still pending.

Review of Patient #2's clinical record revealed the facility admitted the patient on 01/14/16 with Chronic Respiratory Failure for continued weaning off the mechanical ventilation. The patient was intubated and failed to wean from the mechanical ventilation status post a tracheostomy. Additional diagnoses included Bipolar Disorder, Hypertension, and Acute Kidney Injury.

Observation of Patient #2, on 02/09/16 at 2:22 PM, revealed the patient was awake, but unable to make sounds due to mechanical ventilation. The patient attempted to speak without sound; however, the patient spoke very rapidly and the writer was unable to read the patient's lips. When the writer asked specific questions, the patient would nod his/her head yes or no. The patient nodded their head yes to the perpetrator tried to have sex with him/her. The patient nodded their head no to if they wanted to have sex and if the patient had given consent. In addition, the patient mouthed the word, "No" three times. The patient was able to formulate the words to say the perpetrator had closed the door, removed the patient's underwear, and climbed on top of the patient naked. The patient was consistent in their answers to questions by DCBS, the Police and the SA.

A telephone interview with the Police Detective from the Special Victims Unit, on 02/09/16 at 1:22 PM, revealed a rape kit was performed and the alleged perpetrator was arrested that day. The patient could not answer questions the day of the alleged sexual abuse and really couldn't tell the police what had happened. The patient shook their head yes that the alleged perpetrator had sex with them and shook their head no to indicate he/she didn't want them to. However, the Detective was not sure the patient understood the questions. The Detective stated she had told the facility she would notify Adult Protective Services (Division of Community Based Services, DCBS) but with everything going on, she had forgotten.

Another interview with the Detective was conducted when she came to the facility with a representative from DCBS, on 02/10/16 at 11:58 AM. The Detective stated the patient was much different today than on Friday, 02/05/16, the day of the alleged sexual abuse. She stated the patient was smiling and attempting to answer her questions, but she did not know if the patient had understood her questions. She stated the patient was not smiling and had a frightened look on Friday and she was not able to understand anything the patient attempted to say. She stated the patient knew the alleged perpetrator was in jail and he/she felt safe.

Interview with LPN #1, on 02/09/16 at 1:45 PM, revealed she was Patient #2's nurse the day of the alleged sexual abuse. A nurse aide came to her and reported she heard noises coming from the patient's room that sounded like they were having sex. The nurse went immediately to the patient's room and found the alleged perpetrator naked, on top of the patient. She yelled, "What is going on in here?" She stated the patient's eyes were open, but the patient was not smiling. She yelled for help and a male nurse came to her assistance and removed the alleged perpetrator from the patient's room. The alleged sexual abuse was reported to the facility's CEO and the police. The patient was alert and oriented to self and place at times and would normally smile and tried to speak. However, because the patient spoke so rapidly, the staff could not understand what the patient was attempting to say. She stated the patient communicated by nodding their head yes or no to questions.

Continued interview, on 02/09/16, with the CEO and CCO revealed the alleged perpetrator had visited the patient many times and had not indicated any inappropriate behaviors before the alleged sexual abuse. The CEO stated she had interviewed the patient with the police, but had not concluded her investigation. She stated the patient was not sedated at the time of the interview and according to what the patient told the police, sex was not consensual. She stated she had not reported the alleged abuse to the SA because the police told her they would. However, it was her responsibility to report the alleged sexual abuse to the SA, but she did not know that at the time of the incident.

Based on observation, interview, and review of the grievance records, it was determined the facility failed to answer call lights promptly and provide nursing care for six (6) of eleven (11) sampled patients. Patients #1, 4, 7, 8, 10 and #11.

The findings include:

Review of the facility's Grievance Policy, dated February 2013, revealed one of the purposes of the Grievance Process was to provide a quality improvement approach to evaluate the effectiveness of the complaint and grievance process and to identify and implement improvement as indicated.

Interview with the Chief Executive Office (CEO), on 02/09/16 at 1:30 PM, revealed the facility did not have a specific policy that addressed call lights. Any complaint received regarding call lights would be addressed under the grievance process.

Review of the admission packet given to each patient revealed the facility informed the patients that staff would visit each patient's room to reduce the need to use the call light. The facility informed the patient that when they did activate the call light, their goal was the patient always got help as soon as the patient wanted it.

Observation, on 02/10/16 at 8:35 AM, revealed the call light in Room 420 was activated. At the Nurses' Station an audible sound at the call light panel with the room lighted to indicate Room 420's call light had been activated. Continued observation revealed the staff had not responded to the call light by 8:45 AM. At that time this writer walked to Room 420 and observed the patient sitting up in a recliner holding the call light device in his/her hand. At 8:50 AM, staff responded to the call light.

Interview with the patient in Room 420 (Patient #10), on 02/10/16 at 11:16 AM, revealed he/she had activated the call light earlier because they needed to be suctioned. The patient had a tracheostomy and was on mechanical ventilation; however, the patient was able to speak in low tones. The patient stated he/she had waited 25-30 minutes before their call light was answered.

Interview with Patient #4, on 02/09/16 at 11:46 AM, revealed the patient had to wait up to thirty (30) minutes before the call light was answered. The patient stated he/she had waited on pain medication before and that was uncomfortable.

Interview with Patient #7, on 02/09/16 at 4:03 PM, revealed there were major problems with the staff responding to call lights. He/She had to wait 30-40 minutes before their call light was answered. The staff would turn off the call light at the Nurses' Station and would not come to the room to see what the patient needed. He/She had used their own personal cell phone to call for help before. The patient stated he/she had been in pain and waited for their pain medication for 20-30 minutes. He/She had informed the Charge Nurse, Chief Clinical Officer (CCO), and the CEO about the call lights not being answered promptly and staff turning the lights off at the Nurses' Station with little improvement. However, it was a major problem that needed to be fixed. The patient explained he/she was totally dependent on staff for everything including pain medications and was afraid the staff would not provide the care needed.

Review of the Grievance Log revealed Patient #7 had voiced a concern regarding call lights being turned off at the Nurses' Station on 12/29/15. The grievance investigation found the Unit Secretary had left the Nurses' Station unattended and nobody answered the call light. The Unit Secretary was re-educated regarding desk coverage at all times and the staff was re-educated on call light response. On 01/29/16, the patient voiced another grievance regarding the call light being turned off at the Nurses' Station without asking the patient what he/she needed. The grievance found the Night Shift Supervisor also activated the call light in the patient's room with no answer at the desk. She then called the Nurses' Station with no answer. The supervisor documented she had been in the patient's room for over five (5) minutes. The Supervisor further documented she left the patient's room and walked to the Nurses' Station and found the Unit Secretary sitting there. She then addressed the issue of not answering the call light with the employee. She told the Unit Secretary she could not ignore any call lights or calls. The CEO signed off on the grievance as resolved and included the education the Night Shift Supervisor had given the Unit Secretary.

Patient #8 filed a grievance on 12/31/15 regarding call lights. The patient told the investigator he/she could not receive the help he/she needed when they pushed the call light button. The Unit Secretary had hung up on him/her upon the call light activation. The patient voiced the need to be suctioned. In addition, the patient reported to the investigator it was worse at night and it took forty-five (45) minutes for staff to respond to the call light request to be suctioned. The allegation of the grievance involved the Respiratory Therapy (RT) Department. The Unit Manager and the RT denied the allegations. Staff was instructed to answer all patient calls/requests for suction in a timely manner.

Review of Patient #11's grievance, filed on 12/28/15, revealed the patient's wife had requested staff to clean the patient after having bowel incontinence. The wife stated she had waited for over an hour for someone to come and clean the patient. Education was given to the nurse and nurse aide assigned to the patient that day and included call light response time.

Interview with Patient #1's family member, on 02/10/16 at 10:04 AM, revealed there was not enough staff to care for the patients. The family member stated call lights were not answered promptly or the staff would turn the call light off at the Nurses' Station. Sometimes the staff would answer the call light via intercom, but it took the staff awhile before they came to the room to assist the patient. The family member stated the patient laid in stool for sometime before the staff came and cleaned the patient.

Interview with the CCO, on 02/10/16 at 10:22 AM, revealed she and the CEO were aware there was a call light response problem and she had planned on addressing this issue with the staff. She had reviewed the grievances filed regarding call lights and had spoken with some patients and families. She stated she had observed for call light response by watching the staff. However, she had not conducted any call light audits. She stated the call system was old and did not record the response times of the call lights; nor had she timed the response time of the call lights either. She stated she was unaware the call lights could be turned off at the Nurses' Station.

Observation of the Nurses' Station, on 02/10/16 at 8:35 AM, revealed Nurse Aide #1 demonstrated how a call light could be turned off at the Nurses' Station.

Interview with the Patient Relations Representative, on 02/09/16 at 10:52 AM, revealed she would look at call lights not being answered as a complaint. She would try to resolve the issue, if not, would write it up as a grievance. In addition, she would look at staffing. She stated she did not always ask about call light response times during her visits with the patients and families.