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Based on record review and interview, the facility's direct care staff failed to promote and maintain the rights of its patients, by ensuring patients receive care and services in a safe setting free from abuse/ neglect in 2 of 10 sampled patients. Patient #s 1 and 8

Findings:

Review of the facility's current policy and procedure on Abuse/ Neglect (suspected): Elderly or dependent Adult. Policy # 4138595 direct facility's staff as follows:

"Definition Sexual assault: Any unwanted, non -consensual sexual contact against any individuals by another."

"Abuse: The willful neglect or infliction of injury, unreasonable confinement, intimidation, non- consenting sex, or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker or one's self of goods or services that are necessary to avoid physical harm, mental anguish or mental illness."

"Physical Neglect: Consistent hunger, poor hygiene, inappropriate dress."


Patient #1
Review of Patient #1's clinical record, revealed a physician's order dated 03/05/2018 for admission to The Senior Care Unit at the hospital for in-patient unit with diagnosis of dementia with behavioral disorder.


Review of clips from video camera provided by Facility's Administrative staff.
Review of a series of video camera recording of incidences captured on the Senior Care Unit of the facility documented as follows:

(1) Incident recorded on 03/06/2018 at 10:15 p.m. - 10:30 p.m.: Patients #1 and a female patient, identified as Patient #8 were observed on video recording entering the media room which is located on the left of the entry way to the Senior Care unit. Both patients were utilizing rolling walkers. The female patient's walker had a seat which had a collection of paper on the seat.
After entering the media room, both patients sat on the sofa directly facing the door of the media room. The patients were seen on the video clip, hugging each other and then the male patient placed his hand on the female's thigh and caressed and kissed her thigh. The female patient #8 in return kissed the male patient's cheek. The male patient then removed his penis from his pants and placed it in the female patient's hand. The female patient then directed the male patient to give her some paper that was on the seat of her walker. She then used the paper to disguise the male patient's exposed penis. They then continued to sit on the sofa while the female patient appeared preoccupied in ensuring that the male patient's exposed penis was covered.

The male Patient #1 then stood up, pulled his pants down to his knees and exposed his penis/ genital area and buttocks. The female Patient #8 then used a blue cloth/towel to cover the male patient's exposed genital area, while they continued to kiss and her hand remained under the blue cloth/ towel covering the male patient's penis/ genital area.

At 10:28 p.m. A Male staff entered the room, identified by Facility's Administrative Staff as Registered Nurse (B). He entered the media room and had an inaudible dialogue with both patients. Registered Nurse (B) had a smile on his face while talking to both patients. The male patient then proceeded to pull his pants up from his knees, grabbed his walker and left the room behind the male nurse, while the female patient followed behind later.

(2) Incident recorded on 3/10/2018 at 8:58 p.m. - 9:13 p.m. A male individual identified by Facility's Administrative staff as Patient #1 was observed on the video recording, walking in the sitting area of the unit. The Patient was wearing a pair of paper pants with both feet in one leg of the pants. A male staff identified by Facility's Administrative Staff as Registered Nurse (F) was observed sitting in the sitting area at the computer station on wheels. The Patient approached Registered Nurse (F) and there was an inaudible exchanged of words. The Patient responded verbally (inaudible). The Patient attempted to continue walking by pushing away the nurses' hand.
Registered Nurse (F) raised his left hand and pushed Patient #1 in his chest. Registered Nurse (F) grabbed the Patient, the Patient fell to the floor.
Another male staff, identified by Facility's Administrative staff as Registered Nurse (B) approached the Patient along with Registered Nurse (F). Both registered nurses dragged the Patient along the floor, using the patient's arms, vest and shirt to drag the Patient on the floor out of site of the video. During the incident a foot of the Patient's shoes came off. The Patient did not show signs of aggression during the incident.

(3) Incident recorded on 3/10/2018 at 9:26 p.m. - 9 41 p.m.; A Male Patient identified by Facility's Administrative Staff as Patient #1 was observed on video recording walking in the sitting area of the Senior Care Unit. The Patient was wearing clothing with a large stain at his buttocks. The Patient picked up a towel and threw it in the chair, and then the Patient attempted to exit the sitting area. While exiting the sitting area, the Patient picked up a black object from a chair. The Patient swung the black object at a male staff identified by Facility's Administrative staff as Registered Nurse (B). Registered Nurse (B) forcefully pushed the patient to the floor in the sitting area of the unit. Observation revealed a foot of the Patient's black shoe on the floor. Registered Nurse (B) picked up the shoe from the floor.
Another male staff identified by Facility's Administrative Staff as Registered Nurse (F) approached the Patient who was lying on the floor. The Patient got up from the floor and Registered Nurses (B) and (F) dragged the Patient out of sight of the video. The Patient did not show sign of aggression while lying on the floor or being dragged.

(4) Incident recorded on 03/10/2018 at 10:10 p.m. - 10:25 p.m.: A Male Patient identified by Facility's Administrative Staff as Patient #1 was observed in the video recording. The Patient was sitting in a chair identified by the Facility's Chief Nursing Officer as the chair generally used by Registered Nurse (B). After sitting in the chair, the Patient was approached by a male staff identified by Facility's Administrative staff as Registered Nurse (B). Registered Nurse (B) pulled the Patient from the chair via both arm and forcefully pushed him into a Geri chair located near to the chair the Patient was sitting in. The Patient did not show any sign of aggression.

(5) Incident recorded on 03/11/2018 at 4:35 a.m. - 5:05 a.m.: A male Patient identified by Facility's Administrative Staff as Patient #1 was observed in the video recording sitting in the Geri-chair in the sitting area of the Senior Care Unit. The Patient was naked from his waist down with his pubic/ genital area exposed. The Patient's shoes were on the floor below his feet. The Patient attempted to rise from the chair, stepped on his shoes and fell to the floor. The Patient fell at 4:35 and 30 seconds. The Patient remained on the floor for 17 minutes. He was wheeled from the unit at approximately 19 minutes after falling.

During the incident a male staff identified by Facility's Administrative staff as Registered Nurse (B) was present at the nurses' station with his back to the Patient. Another individual identified by Facility's Administrative Staff as Registered Nurse (F) was sitting in the nurses' station. Registered Nurse (B) walked up to Patient #1 who was lying on the floor with a pool of red substance near his head, gave a cursory look at the Patient, stepped over the Patient's body on the floor, then walked away. This red substance was identified as Frank blood noted on the floor near the Patient's head.

A female individual identified as Charge Nurse (G) walked over to the Patient, bent over the Patient, touched the Patient and walked back to the nurses' station. The Patient remained on the floor with the red substance near his head.

A male nurse identified as Registered Nurse (F) picked up a towel and proceeded to wipe the blood from the floor with his foot. The nurse's foot used to wipe the blood from the floor was in close proximity to the Patient's face who was on the floor.
He then returned to the computer on wheels, sat down and proceeded to write. The Patient remained lying on the floor unattended by facility's staff.

Registered Nurse (B) with his back to the Patient reviewed records while the Patient remained on the floor. The Patient attempted to get up from the floor unattended. The Patient remained on the floor for approximately 17 minutes.

Observation of the video recording revealed, there was no assessment, neurological assessment, or emergency care provided to the Patient lying on the floor with his head in a pool of blood.

After approximately 17 recorded minutes, the Patient was placed in a wheelchair and rolled from the unit. The Patient left the unit for the emergency room after approximately 19 minutes.


Review of a physician's progress notes (Emergency Provider Report) dated 03/11/2018 at 0546 revealed the following documentation; "76 yr male presents to the ED from Senior Care at this hospital c/o forehead laceration s/P fall today. Fell out of chair and hit forehead on floor. No LOC, per triage notes. Trauma general: Laceration (3 cm gaping wound, Lt forehead.)"
0602 "Location of wound: left forehead. Wound Length: (cm) 3. Sutures 6."


Review of a Fall Audit Post Fall Debrief Record, dated 3/11/2018, revealed the following documentation: "Pt was encouraged to go to bed numerous times but refused. Fell asleep in the day area. Tried to get up while he was drowsy and fell." Laceration to head stitched."


Interview with Facility's Chief Nursing Officer
Interview with the Facility's Chief Nursing Officer on 03/27/2018 at 9:10 a.m. revealed the Senior Care Unit is currently closed in relationship to a pattern of incidences which happened on March 6th, 10th and 11th 2018. She said Patient #1's family informed the facility that the Patient alleged that he was pushed by a staff and sustained a cut to his face. She said while doing the investigation and reviewing video clips, the facility discovered a pattern of abuse neglect of patients on the unit by facility's staff. Monitoring of the unit with outside staff was implemented and a report was made to the Licensing agency.

She said the incident of patient to patient sexual abuse was brought to the facility's attention on March 22, 2018 and a decision was made to cease admissions to the unit. Patients who could be discharged, were discharged to home and other patients were transferred to various facilities in the community. She said the unit is currently under renovation focusing on the door knobs which are ligature risks and some cosmetic renovation.
She said the facility's administrative staff are currently evaluating processes and policies in the operation of the unit along with staff training. She said as a result of the investigation, three staff member were terminated and retraining of all staff have begun. The staff terminated were referred to the Board of Nursing. Patient #1 was transferred to a sister facility.

Interviewed Units Intake Coordinator
Interview on 03/27/2018 with the Unit's Intake Coordinator(I) revealed, Patient #8 was a caretaker who attempted to go from patient to patient to check on them. As a result, the Patient had to be redirected constantly.
He said Patient #1 was manic with poor boundaries. He said both patients had no history of sexually acting out. He said the facility was not made aware of the incident until after the female patient was discharged. He said Patient #1 was admitted to the unit on March 5th, the incident happened on March 6th and the Female Patient was discharged from the facility on March 7, 2018.

Interviewed Registered Nurse (A)
Interview on 03/27/2018 at 11:41 a.m. with Registered Nurse (A) in the presence of Facility's Chief Nursing Officer revealed, on the night of March 6, 2018 while going to the bathroom, she saw two patients in the media room of the Senior Care Unit. The male patient was sitting on the sofa while the female patient was standing.
On returning from the bathroom, she saw both patients sitting on the sofa close together. She stated "It seems they were getting too friendly." She said she went back to the nurses' station and reported what she saw to Registered Nurse (B), one of the nurses on the unit.

She said she had never observed any of the patients sexually acting out. She said Patient #8 was a caregiver, in the past was a preacher who liked to take care of others. She said at times when the media room is opened patients are allowed to go in and listen to the radio or read a book.

Interviewed Registered Nurse (B)
During an interview via the telephone with Registered Nurse (B) on 03/27/2018 at 12:00 noon, revealed he said, on the night of March 6, 2018 Patient #1 was in a room with a Lady Patient (Patient #8). He said he was not assigned to the Lady Patient. He said the patients were sitting down with their arms around each other. He told them they could not do that.
He said he saw Patient #1 with a towel on his lap, and asked the Patient "What's going on with that towel." He picked up the towel and noticed that the Patient's pants were down to his knees. He said he directed them out of the room.,

Registered Nurse (B) said he saw when both patients entered the media room, that they were there for approximately 4 minutes and that he was "giving them a chance." He said he had gone in to check on them, when he witnessed the incident. He said he reported the incident to the staff on the unit but he could not recall who was the Charge Nurse.
When asked if he had completed an incident report, he said he did not make out one "because nothing happened." He stated "Whatever they were going to do I stopped it."

He said there was another incident with Patient #1 on March 11th where the Patient got up out of his chair and fell. He stated "I tried to catch him from falling but I could not." He said the Patient had blood on his hands and that was when he noticed that the Patient had a cut on his head.

Interviewed Unit Manager (H)
Interview with Senior Care Nursing Manager (H) revealed he was made aware of the incident on March 22, 2018. Patient #1 was transferred to a sister hospital.
He said the nurses reported that Patient #1 tried to grab at the nurses. He said the Patient stayed in the day area most of the time when he was not sleeping.


Interviewed Registered Nurse (M)
Interview on 03/28/2017 at 8:00 a.m. with Registered Nurse (M) revealed, she has been working in the facility for approximately 7 months under the Star New Graduate Program. She said she did receive training on abuse neglect.
She said on the night of the incident on 03/06/2018 she could not recall if she was assigned to Patient#1.
The Surveyor then reviewed the 15 Minutes Rounding Sheet which showed her signature monitoring the patient on the night of the incident.

She said she did not see the patients in the media room but Registered Nurse (B) told her that he saw the male patient with another female patient and they were trying to touch each other. He immediately took them from the media room. Registered Nurse (B) took the female Patient#8 and she took the male Patient #1 to his room.
The Surveyor then reviewed the 15 Minutes Rounding Sheet with Registered Nurse (M). The Surveyor informed her that she had documented that she had rounded on the patient at 22:15 that the Patient was in the media room sitting at 22:15. She said there was no area on the monitoring sheet for media room and that was the reason why she documented day room.

She said, the practice on the unit is to trade hours, i.e. one nurse round on the patients every 15 minutes for one hour intervals, and the nurse assign to the patients document on the rounding sheet although the nurse did not actually see the patients. The Fifteen Minutes Rounding sheet is not shared with each other.
She stated "That's how I was trained. I never knew better. "

Interviewed Registered Nurse (F)
On 03/28/2018 at 8:48 a.m. the Surveyor received a telephone call from a female who identified herself as a lawyer representing Registered Nurse (F) who wanted to be on the telephone call during the interview with her client.
The Surveyor informed her that during an investigation by Agency Personnel, lawyers are not accommodated. She then notified the Surveyor that her client would be calling the Surveyor.

Interview on 03/28/2018 at 8:52 a.m. with Registered Nurse (F) via the telephone revealed, the Surveyor asked the Registered Nurse if they were the only two individuals on the telephone. Registered Nurse (F) Informed the Surveyor that the interview was between the Surveyor and the Registered Nurse and there was no other party on the telephone.

Registered Nurse (F) stated "I came back from Florida. I wasn't assigned to Patient #1 but I helped Registered Nurse (B), the nurse who was assigned to him. The Patient was sitting in a chair, he was aggressive earlier on and refused to follow orders. I helped Registered Nurse (B) to change him in his room and he gave him medication to calm him down. He removed his underpants and came out without the bottom. He sat in the chair and fell asleep in the chair. We did not want to wake him because the medication had taken effect.

Later in the morning I was sitting behind the desk at the nurses' station and Registered Nurse (B) was standing in front of the desk. I saw him look around. I asked Registered Nurse (B) what happen? He said "The gentleman had fell." I asked him if he was ok. Registered nurse (B) told me I think he hit his eye and there was blood.
I came out of the room and Registered Nurse (B) went to get the Charge Nurse. The Charge Nurse came and assessed the Patient. I stayed with the Patient while the Charge Nurse and Registered Nurse (B) went to get a wheelchair and vital signs monitor. They only came back with only the wheelchair. Nobody did vital signs on the Patient. I put a towel on a small amount of blood on the floor.

I tried to do my best at all times. I have never abused or witness abuse on any patients. I have pulled patients by the hands because he was resistant. No one was trying to abuse the patient. I was shown video of the Patient on the floor and me standing there. He was taken to the ER I don't know how many sutures he received."
The Surveyor then asked Registered (F) if he was able to see if the Patient was still bleeding while he was lying on the floor. He stated that he was able to visualize the cut on the Patient's face and that the bleeding did not persist although staff did not arrest the bleeding.

Interviewed Licensed Vocational Nurse (P)
Interview on 03/28/2018 at 9:30 a.m with Licensed Vocational Nurse (P) in the presence of Facility's Chief Nursing Officer revealed, she has been working at the facility for approximately 6 months.
She said Patient #1 was sometimes sexually inappropriate. She said on one occasion the Patient was sitting in a Geri-chair, he remarked that he had a chair like the one he was sitting in at home and implied what he would do to her.
She said she cannot recall any patient to patient sexual abuse, but could recall another Patient trying to kiss and hug another female patient. She said the patient had to be redirected and kept them apart.

Based on record review and interview, the facility's registered nurse failed to supervise the care of patients in 2 of 10 sampled patient. Patient # 1 and 8


Patient #1
Review of Patient #1's clinical record (Fifteen Minutes Rounding Sheet) dated 03/06/2018 revealed documentation which indicated that the Patient was in the day room at 2215 and 22:30.
The Fifteen Minutes Rounding Sheet also indicated that Patient #1 was monitored by Registered Nurse (M) for the entire night.

The Surveyor then reviewed the 15 Minutes Rounding Sheet with Registered Nurse (M). The Surveyor informed her that she had documented that she had rounded on the Patient at 22:15 that the patient was in the media room sitting at 22:15.
She said there was no area on the monitoring sheet for media room and that was the reason why she documented day room.
She said, the practice on the unit is to trade hours, i.e. one nurse round on the Patient every 15 minutes for one hour intervals, and the nurse assign to the patient document on the Fifteen Minutes Rounding Sheet, although the nurse did not actually see the patients. She said the Fifteen Minutes Rounding Sheet is not shared with each other.
She stated "That's how I was trained. I never knew better. "


Patient #1
Review of Patient #1's clinical record (Fifteen Minutes Rounding Sheet) dated 03/11/2018 indicated that the Patient was monitored by Registered Nurse (B) in the following environment:
04:30, 04:45, 05:00, In room with staff sleeping and breathing.
05:15, 05: 30: In room with staff toileting.
05:45, 06:00, 06:15, 06:30, 06:45: In room with staff.

However, Review of the Patient's Emergency Room Provider Report dated 03/11/2018 documented that Patient #1 was in the emergency room at the following times.
0509: Point of Care Testing, Temperature, Pulse, Respiration, blood pressure and pulse Ox performed in the emergency department.
0602: Patient wound to left forehead sutured.
0630: Patient at radiology - XR pelvis ½ views.
0638: Patient at CAT Scan.

Registered Nurse (B) documented that he was supervising the care of Patient # 1, while the Patient was off the Senior Care Unit to the Emergency room for treatment, for a laceration he obtained when he fell on the Senior Care Unit.

Patient # 8
Review of Patient #8's, Fifteen Minutes Rounding Sheet dated 03/6/2018 revealed documentation which indicated that the Patient was monitored by Registered Nurse (B) at 22:15, 22:30, 22:45 as being in the day room.

Review of a Video Clip provided by Facility's Administrative Staff revealed the Patient was in the Media room of the facility with Patient #1.