LA FAYETTE, GA – PRUITTHEALTH – SHEPHERD HILLS

Based on record review, staff, family and Physician interviews, review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to notify the Physician and the Responsible Party of a sexual abuse allegation for one resident (R) (R C). The census on 10/22/2020 was 94.

On October 27, 2020, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.

The facility’s Administrator and Corporate Consultant Nurse were informed of the Immediate Jeopardy on October 27, 2020 at 12:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on October 16, 2020. The Immediate Jeopardy continued through October 28, 2020 and was removed on October 29, 2020.

Immediate Jeopardy is outlined as follows:

On October 16, 2020 at approximately 8:00 p.m. Temporary Nursing Assistant (TNA) AA, reported to Registered Nurse (RN) CC that R C reported to her that TNA DD, had sexually assaulted her. RN CC, along with TNA AA immediately went to the Social Services Director (SSD) and reported the allegation to her. RN CC instructed TNA AA, to switch her assignment with TNA DD to prevent him from caring for R C. Review of the Police Department Incident Report revealed on October 20, 2020 at 7:00 p.m. an incident was filed, by a family member, that R C reported to her that she had been sexually assaulted by TNA DD. During an interview on October 22, 2020 at 12:30 p.m. with the investigating Detective at the Police Department revealed that he arrived at the facility on October 20, 2020 sometime between 7:00 p.m. and 8:00 p.m., prior to his arrival, he made a telephone call to the facility and discovered that TNA DD was still in the facility at this time. The Detective stated he instructed that the facility remove TNA DD immediately from the building. Review of a written statement by the Director of Health Services (DHS) dated October 20, 2020 (no time indicated) revealed she was notified after the police arrived and that TNA DD had been accused of sexually assaulting one of the residents. The DHS then suspended TNA DD at this time until an investigation was completed, and that TNA DD left the property at that time.

An interview with R C on 10/22/2020 at 11:30 p.m. revealed that one day last week, and added she was not good with remembering days and times, she pressed her call light because she had wet her brief and needed changing. She stated she was in the bed with the head of the bed up when TNA DD came in her room. The resident stated she had always like TNA DD and stated he was nice and polite, and respectable. She stated sometimes she is hard to please when it comes to men but stated she had come to trust TNA DD. She stated he came over, pulled the curtain, and pulled her gown up and saw that her brief was wet. He then placed his knee between her legs, leaned forward and put his penis in her mouth. She stated he grabbed her mouth and held her lips around his penis until he ejaculated into her mouth and stated it made her sick. The resident stated that TNA DD told her they were going to have to work on that. She stated he kept asking her if she was going to tell anyone and she told him no. She stated she told TNA AA about it a few days later and TNA AA reported it, but that nobody did anything about it.

A telephone interview on 10/22/2020 at 3:25 p.m. with CNA AA revealed that R C told her that TNA DD had put his penis in her mouth. CNA AA stated she immediately told Registered Nurse (RN) CC and stated RN CC told her to change assignments with TNA DD and do her job and not to worry about it.