State Findings:
Based on interview, record review and review of the facility’s Policy, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse for one (1) of ten (10) sampled residents (Residents #5).Record review revealed Resident #4 had a history of [REDACTED]. This incident was investigated by the State Survey Agency during the facility’s standard survey concluded on 08/29/19. Although Resident #4’s Comprehensive Care Plan was initially revised on 08/28/19 related to sexually inappropriate behaviors towards other residents with an intervention for every fifteen (15) minute checks, this intervention was discontinued on 08/30/19. Interview and record review revealed the resident’s Comprehensive Care Plan was not further revised with interventions, related to his/her sexually inappropriate behaviors towards other residents, in an attempt to prevent recurrence, and staff was unaware of Resident #4’s sexual behaviors.
On 12/15/19, at approximately 2:00 PM, Resident #4 was witnessed to have his/her hand on Resident #5’s breast, and staff immediately separated the two (2) residents. Resident #4 was placed on fifteen (15) minute checks while in his/her room and one to one (1:1) monitoring while out of the room; however, this was only for the remainder of the shift until 7:00 PM.
There was no documented evidence of continued monitoring of Resident #4 related to the resident’s history of sexually inappropriate behaviors towards other residents. Staff interviews on 01/02/2020, revealed Resident #4 was not currently receiving increased monitoring or supervision for inappropriate sexual behaviors.
Additional interview with the DON, on 01/13/2020 at 10:00 AM, revealed on 01/03/2020 at 7:00 PM, after Surveyor intervention, Resident #4 was placed on one on one (1:1) observation around the clock, indefinitely. Per interview, facility staff and contracted agency staff provided coverage. The DON stated there could be negative consequences if residents were not monitored as necessary related to sexual behaviors towards other residents. Per interview, it was her expectation residents were monitored as necessary in order to be free from abuse.
Your Experience Matters
...and we want to hear it.
NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
You can make a difference, even if your loved one has already passed away.
Please give us a call at 1-800-645-5262 or fill out our form detailing your experience.
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.
If you are struggling and upset, click here to understand your options, or contact us through our contact form or call our toll free hot line number: 1-800-645-5262.
