PHOENIX, AZ – LA ESTANCIA NURSING AND REHABILITATION CENTER

Based on clinical record reviews, facility documentation, staff and resident interviews, and policy review, the facility failed to ensure that one resident (#2) was free from sexual abuse by another resident (#1) and failed to ensure one resident (#3) was free from physical abuse from another resident (#2). The sample size was three residents. The deficient practice could result in the potential for further resident to resident abuse.

An interview was conducted on (MONTH) 3, 2019 at 10:00 a.m. with an LPN (Licensed Practical Nurse/staff #56). Staff #56 stated that although she had worked on (MONTH) 30, 2019 on the night shift, she had been temporarily away from the unit when the incident had occurred at 12:00 a.m. Staff #56 stated that upon return to the unit she assessed resident #2, and observed that resident #2 remained in bed and was very quiet for the remainder of the night which was very unusual for her. Staff #56 stated that the normal night time behavior for resident #2 was to be up and awake all night, spending her time in the dining room or out in the courtyard and that it was highly unusual that she remained in her bed.

An interview was conducted on (MONTH) 5, 2019 at 12:00 p.m. with a case manager (staff #99). She stated that resident #2 had an extensive history of physical and sexual trauma dating back to her childhood that included rape and that resident #2 had told her family member (regarding resident #1), He hurt me and put his mouth on me.