LAS PALOMAS CENTER
LOCATED: 8100 PALOMAS AVENUE, ALBUQUERQUE, NM 87109
LAS PALOMAS was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO PROTECT EACH RESIDENT FROM ALL ABUSE, PHYSICAL PUNISHMENT, AND BEING SEPARATED FROM OTHERS
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to ensure that residents were free from alleged sexual abuse for 1 (R #1) of 4 (R #1, 2, 3, 4) residents reviewed for abuse. This deficient practice resulted in R #1 experiencing feelings of anxiety, fear, discomfort and led to her having nightmares. The findings are:
On 12/30/16 at 8:22 am, during an interview with the PTA (physical therapy assistant), she stated that R #1 came to therapy and told her that something strange happened. R #1 told PTA that on 09/12/16 she woke up to CNA #1 (certified nursing assistant) massaging her. PTA stated that R #1 told her that she woke up and CNA #1 was sitting on her bed and rubbing her. PTA also stated that R #1 was very concerned when telling her what happened.
On 12/30/16 at 8:31 am, during an interview with the DON (Director of Nursing), she stated that R #1 told her that there was not penile penetration, but that CNA #1 did put his hand in R #1’s vagina. The DON stated that after R #1 disclosed this to her she (R #1) did agree to get a SANE (Sexual Assault Nursing Exam).
On 12/30/16 at 10:10 am, during an interview with the SSD (social services director) she stated that she was the first person to interview R #1 regarding the alleged abuse. The SSD stated that R #1 informed her that the encounter took place after she (R #1) went to bed and lasted around thirty minutes. The SSD also stated that R #1 wasn’t able to pinpoint the exact time of the alleged abuse because it was very dark in the room at that time. R #1 told SSD #1 that CNA #1 was going to massage her leg and she told him that is not my leg.
On 12/30/16 at 10:45 am, during an interview with CNA #1, he stated that he was called in by the Administrator and the Administrator told him that there was a complaint filed against him alleging that he touched one of the residents inappropriately and he was being suspended. CNA #1 stated that he didn’t know who said these things about him. He stated that he was currently still suspended from going back to work. CNA #1 stated that he had not ever given a resident a massage. When asked again, CNA #1 then stated that he had given one resident a neck massage and that this resident was very independent and he had given this resident a neck massage in front of everyone.
On 12/30/16 at 1:58 pm, during an interview with R #1, she stated that CNA #1 had come into her room about one month prior and had told her that he would massage her leg because he knew it had been hurting. She stated that he told her that his wife lived in Mexico and also told her don’t worry, don’t worry my wife is a white woman. She stated that she didn’t understand or know why he had told her that. She thought it was odd. R #1 stated that she woke up and CNA #1 was massaging her. She stated that she didn’t have a roommate at that time. She stated that she was unsure of the exact time, but that she had the TV on because the TV helps her fall asleep at night and that the curtain was drawn and it was dark, but she thought that this happened between 9:00 pm and 10:00 pm. R #1 also stated that she saw CNA #1 the next day and he told her that he would see her tonight. She stated that she just didn’t feel right about it and it wasn’t ok, so she told the PTA. R #1 also stated that Massaging my leg is one thing and probing my crotch is another. She also stated that she started having nightmares a couple of weeks ago. She stated. that another thing about rape and incest is you let them do it and then you get out alive. At 62, I’m not a sexy person so I’m not sure why he did that or why he chose me. She indicated that she had a good rapport with CNA #1 before the incident happened with him and that after the incident and after she told everyone, she withdrew and became more depressed.
On 01/03/16 at 10:45 am, during a phone interview with the Registered Nurse (RN) who performed the SANE exam, she stated that R #1 arrived in her wheelchair and notified her (nurse) that she (R #1) had some right sided weakness. The SANE Nurse stated that R #1 told her that she was digitally (by hand) penetrated by CNA #1. The SANE Nurse stated that anytime there is bruising on the cervix, it is caused by internal friction or trauma. She stated that the specific bruising on R #1’s cervix, in her professional experience, appeared like it could have been caused by a fingernail. She also stated that there has to be penetration and trauma to the cervix to create a bruise. She stated that R #1 told her that she was unable to use her call light/call button, because the button was on the right side of the bed, she was unable to get it and she was scared. R #1 told the SANE nurse that she (R #1) was concerned about the [AGE] year old resident’s and didn’t want this happen to one of them.
On 01/11/17 at 10:45 am, during an interview with the Violent Crimes Detective, she stated that when she interviewed R #1 she was clear, consistent, and detailed. She stated that her investigation was ongoing at that time.
Record review of R #1’s medical record indicated that on the night of 09/12/16, the day of the alleged abuse, R #1 did not have a roommate.
Record review of the investigative report dated 09/12/16 indicated that CNA #1 worked the night of 09/12/16. He clocked in at 1:55 pm and clocked out for dinner at 9:11 pm, clocked back in at 9:40 pm and clocked out for the evening at 10:10 pm. R #1 stated that she thought the incident occurred between 9 pm and 10 pm.
Record review of the SANE report written and filled out by the SANE RN indicated that her findings were:
Note: white/cream discharge noted on cervix, collected with cervical swabs.
Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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