ROME, GA- WINTHROP HEALTH AND REHABILITATION

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38514

Based on observations, record review, interviews, and review of the facility policy titled, Abuse Prohibition, the facility failed to effectively address the sexually aggressive behavior of one of four residents (R#364). The facility failed to put effective interventions in place to protect three of four residents (R#17, R#55, R#42) from resident-to-resident sexual abuse. The deficient practice had the potential to affect all 61 residents residing in the facility

On 04/14/2022, 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 was informed of the Immediate Jeopardy (IJ) on 04/14/2022 at 7:46 PM. The noncompliance related to the immediate jeopardy was identified to have existed on 05/23/2021. The immediate jeopardy was removed on 04/17/2022.

The IJ is outlined as follows:

The IJ began on 05/23/2021, when R#364 was found in the room of R#17, a resident with severe cognitive impairment, with his hands under the resident’s shirt on the resident’s breasts. On 5/23/2021, R#17, reported to staff that she had been molested. The facility failed to put interventions in place to prevent future incidents from taking place. R#17 was subsequently sexually abused a second time by R#364 on 07/11/2021 when R#364 was found with his hands under R#17’s shirt. Additional residents were sexually abused by R#364. R#55, a bedbound resident with moderate cognitive impairment, was sexually abused by R#364 on 08/27/2021, when R#364 was observed in R#55’s room, with his hand under R#55’s cover. R#55’s brief was
observed to be un-taped and folded back. On 1/21/2022, R#364 was found with his hand on the chest of R#42 another resident with severe cognitive impairment. The facility failed to address the sexually aggressive behavior of R#364 and failed to put effective interventions in place and therefore failed to protect R#17, R#55, and R#42 from resident-to-resident sexual abuse.

Review of a typed statement, dated 05/23/2021 by RN CCC, revealed that R#364 was seen rubbing R#17’s leg that morning and was told by a nurse (LPN TT) to stop touching R#17 and that this was not okay. R#364 proceeded to follow R#17 around, and R#17 went to the nurses’ station with tears in his/her eyes and said he/she was scared. The statement documented when RN CCC returned from lunch, staff reported that R#364 was found in R#17’s room grabbing R#17’s breasts. RN CCC went to talk to R#17 alone, and R#17 did not remember anyone coming into his/her room. A few minutes later, RN CCC and CNA AAA went to talk to R#17, who then reported to CNA AAA that she was molested by a guy and R#17 told him to get the hell out. The statement indicated a full body assessment was conducted by an RN and LPN and there was no bruising or redness to the chest area or abdomen.

An interview on 04/17/2022 at 12:34 PM with LPN TT, when asked about the incident involving R#17 and R#364 that occurred on 05/23/2021, LPN TT stated she had directly reported the incident to the Administrator and demanded the police be notified because of how afraid R#17 was after the incident. LPN TT stated the previous Director of Nursing (DON) EEE, who was employed at the facility when this event and three other assaults by R#364 took place, did not recognize the seriousness of the incident. LPN TT stated the staff were never told if a report was filed with the state or if there were any new interventions in place for protection of R#17 and other residents, except to watch them closely.

Review of an undated, untimed statement from SW FF indicated the SW asked R#17 if the resident was afraid, and R#17 said no. There was no documentation in R#17’s electronic health record (EHR) regarding the sexual assault.

An interview on 04/17/2022 at 12:34 PM with LPN TT, who stated the facility had a total disregard for the safety of the residents. She stated the staff were never told if a report was filed with the state and if there were any new interventions in place for protection of R#55 and other residents, except to watch them closely.

Review of an email dated 7/12/2021, from the Administrator to Corporate contradicted the handwritten note written by LPN GGG (which documented that LPN GGG was the staff member that observed R#17 in R#364’s room). The email indicted, in pertinent part, that a CNA found R#17 in R#364’s room and that she was in no distress. The email indicated that R#17 (a severely cognitively impaired resident) probably thinks that R#364 is her husband and there is nothing that anyone can do, maybe try and keep them separated, but that would be too hard.

Review of the EHR for R#17 revealed there was no documentation indicating that the resident’s family, or abuse coordinator were notified of the sexual assault on 07/11/2021. There was no nurse’s note or assessment found in the chart related to the 07/11/2021 incident.

Review of the EHR for R#364 revealed there was no documentation regarding the sexual assault on
07/11/2021.