HospitalInspections.org

Based on observation, interview, and record review, the facility failed to protect patients from abuse. Specifically, they failed to not engage an individual with a criminal history of sexual abuse and allowed the individual to eat meals and play Bingo with patients; And the facility did not report to appropriate state agencies, and/or investigate an incident of alleged abuse. Findings include:

1. Review of a typed note from staff member B, dated March 25, 2022, showed "(NF1) had been playing Bingo with the patients and was in the dining room .... (NF1) had kissed (patient #4) on the forehead." NF1 was escorted out of the building.

Review of a typed note from staff member B, dated March 27, 2022, showed NF1 had shown up at the facility around breakfast time. NF1 was told to leave the building.

Review of a typed note from staff member B, dated March 28, 2022, showed that staff members A and B met with NF1, and he was placed on restrictions. The restrictions included, NF1 should only enter the building Monday through Friday. NF1 had to pick one meal to eat that was closest to when Bingo was played. NF1 was to leave the building after Bingo. NF1 had been aware of what he had done on March 25th and apologized for the incident. NF1 was told by staff members A and B "he was not allowed to make those type of mistakes" due to his history. Patient # 4's guardian was notified of NF1 kissing patient #4 on the forehead.

Review of patient #4's medical record showed a note dated 4/11/22 a "Restraining Order was placed restricting any contact with (NF1). 5/4/2022 Permanent Restraining Order ...." Patient #4 is developmentally delayed and needs extensive assist with care. Patient #4 was unable to give consent for physical contact with NF1.

During an interview on 5/23/22 at 1:40 p.m., staff member E said NF1 was allowed to come in and eat meals with the patients at the facility. Staff member E said he is a "registered sex offender" and had kissed patient #4. She said that this incident had been witnessed and there were cameras in the dining room. Staff member E said the incident was reported to administration and did not know if it went any further.

During an interview on 5/24/22 at 8:55 a.m., staff member D said NF1 kissed patient #4 on the side of her forehead. She said NF1 is a "registered sex offender." Staff member D did not feel like this incident was sexual. She said that patient #4 is so loving and will grab people and pull them in close to her. Staff member D said that staff member B took NF1 out of the building. She said the police came up, there was an audio and video of the incident.

During an observation on 5/24/22 at 2:42 p.m., of the video recorded on 3/25/2022, showed NF1 had finished playing Bingo, obtained his cane, walked over to where patient #4 was sitting in her chair. NF1 said "how are you doing (#4's name)?" NF1 patted her hand and patient #4 grabbed NF1's right arm and pulled on him. NF1 was observed to lean over and kiss patient #4 on the forehead. NF1 as he walked by other patients, on his way out of the dining room, was observed to pat another patient on her shoulder and said "goodbye."

During an interview on 5/25/22 at 8:15 a.m., staff member I said on March 25th after Bingo was over, she was busy pulling tables apart and did not notice that NF1 was near patient #4 until she heard staff member D calling her name "Patsy, Patsy!" Staff member I said when she looked at patient #4, she saw NF1 just "coming up from giving (#4) a kiss on the forehead." Staff member I said NF1 usually would come in two days a week for breakfast or lunch. Staff member I said she was not given any special instructions regarding NF1's attendance. She said NF1 sat at the end of the table when playing Bingo. She said NF1 would pat patients on the back and said, "See you later." Staff member I said that six patients attended Bingo and that patient #4 is one that usually attends for stimulation. Patient #4 sits in her chair by me in the dining room.

Patient #4's care plan was requested, but not received by 5/25/22.

2. During an interview on 5/24/22 at 10:00 a.m., staff member B said she thought that a family member had reported the incident that occurred on March 25th to Adult Protective Services (APS) and to the police.

During an interview on 5/24/22 at 11:30 a.m., staff member A said she did not file an initial report, nor investigative report with anyone. Staff member A did not feel it was a reportable incident when NF1 kissed patient #4 on the forehead. Staff member A said that the facility did help provide information to APS and to the police who investigated it. Staff member A and B said they had not received any reports back from APS or the police and were going to try to get a report. Staff member A said NF1 was not able to come back in the building due to the Permanent Restraining Order.