KIRBYVILLE, TX- AVALON PLACE KIRBYVILLE

Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse was provided for 3 of 5 residents reviewed for abuse. (Resident #s 1, 2, and 3)
The facility did not prevent Resident #1, who had a history of inappropriate sexual behavior, from sexually abusing Resident #2 on 9/1/22. Resident #1 was seen walking out of Resident #2’s room. Resident #1 had blood on his thumb. Resident #2 was found with blood in her brief. Resident #1 was heard trying to get Resident #3 to go to his room.

Record review of MDS dated [DATE], indicated Resident #1 had moderate cognitive impairment, ambulated with a walker. He had Other behavioral symptoms not directed toward others which occurred 1 to 3 days. Resident #1 did not exhibit any wandering behaviors.

Record review of Resident #1’s care plan dated 04/11/22 indicated he displayed socially inappropriate behavior and inappropriate sexual gesture with a female resident. Interventions included 15-minute monitoring and sent out to behavioral hospital for evaluation and treatment. 5/6/22 Care plan meeting held with RP & ombudsman. Aware that any inappropriate behaviors would be immediate discharge.

Record review of face sheet dated 9/4/22, indicated Resident #2 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included Alzheimer’s (a progressive neurologic disorder that causes the brain to shrink (atrophy) and brain cells to die).

During an observation on 9/3/22 at 9:43 a.m. with the DON, who verified staff and residents on the secure unit, of the facility’s camera recordings on 9/1/22 from 6:16 p.m. to 7:28 p.m. indicated: At 7:18 p.m. Resident #1 walked out of his room using his walker and stood near the common area.
At 7:21 p.m. CNA A went into Resident #3’s room and closed the door.
At 7:23 p.m. LVN B left the secure unit, leaving no staff to monitor residents.
At 7:24 p.m. Resident #1 walked to his room and leaned against the wall in the hallway.
At 7:25 p.m. Resident #1 walked across the hall into Resident #2’s room.
At 7:27 p.m. CNA A left Resident #3’s room and walked down the hall. She looked in Resident #1’s room and then continued to a closet on hall. At 7:28 p.m. Resident #1 walked out of Resident #2’s room.

Record review of progress note dated 04/11/22 at 4:08 p.m., completed by LVN L, indicated CNA F heard Resident #3 scream no don’t do that when she entered the room. The door was open and she witnessed Resident #1 standing behind Resident #3. Resident #1 was holding on to Resident #3 with one hand, his pants were down and he was exposed. Resident #3’s pants were down and she was exposed. 

Record review of In-service training for CNA A on 7/12/22 and LVN B on 8/22/22 indicated they were trained on Supervision & Monitoring of hall 3 secure unit .There must be hallway monitor in hall 3 at all times-especially when wandering residents or residents at high risk for adverse behaviors are active.

Record review of a progress note dated 9/1/22 at 10:23 a.m., completed by LVN D, indicated Resident #1 was noticed standing at his door looking into the hallway masturbating. The CNA that saw this told him to go to his room, to his bed to do that and he cannot do it outside of his room. After this occurred, he also was asking a female resident to come into his room. The CNA heard this and told him to stop asking female residents to his room, he said OK. Later that day he was seen looking in on female resident lying in bed and redirected by CNA.

Record review of a progress note completed by LVN B dated 9/1/22 at 7:37 p.m. indicated Resident #1 was found in Resident #2’s room by aide and was asked to leave the room. Aide on the hall called for another nurse to come into the unit to assess the residents. This resident (#1) was found with blood on his left thumb by other nurse. Other nurse asked this resident not to wash his hands so that she could take a picture while she was on the phone with the DON. This nurse was in the room assessing resident #2, found blood in resident #2’s brief and around the vaginal and rectal area. DON notified.

During an interview on 9/3/22 at 8:50 a.m., CNA F said Resident #1’s supervision level was 15 minutes checks. She said the 15 minutes checks had been discontinued (unknown date) and then started back on 9/1/22 due to his behaviors. She said he was sexually inappropriate. She said he would masturbate in the doorway of his room. She said there was supposed to be someone in the hallway at all times to monitor residents and ensure Resident #1 did not wander into other female residents’ rooms. She said there was only one CNA assigned to the secure unit from 6:00 p.m. through 6:00 a.m. and the nurse worked multiple halls. She said she was not supposed to leave the hall to do care if there was no staff to monitor the hall. She said there was not a dedicated staff to monitor the hall after 6:00 p.m. She had been trained on abuse and neglect.

During an interview on 9/3/22 at 9:24 AM, the DON said resident #1 was having inappropriate sexual behaviors like masturbating in the hall and saying inappropriate things to staff. The nurses called her around 7 PM on Thursday night and said Resident #1 was seen coming out of resident #2’s room. She was told there was blood on Resident #2’s sheet. She was told LVN C had seen blood on resident #1’s thumb. CNA A said there was blood in the middle of Resident #2’s bed. She said she took a flashlight to Resident #2’s room to assess the resident in order to see any tears in the periarea. She said she did not see any blood or tears in Resident #2’s private area. She said Resident #2 had feces and urine in her brief. She said there was a toenail that had been ripped off and assumed that was where the blood had come from on the bed. She said the staff jumped to conclusions about sexual abuse. She did not think Resident #2 was sexually abused because the blood had come from the toenail and she did not see any blood, just brown feces in the brief. She said Resident #2 was not able to answer any questions. The DON said Resident #1 was sent to a behavior hospital on 9/2/22 due to his increased sexual behaviors. She said she did not report to the state agency or to the police because she did not think there was any sexual abuse. She said she documented in the progress notes about incorrect documentation from the LVN B who thought Resident #2 had been abused.

During an interview on 9/3/22 at 11:35 AM, LVN B said she saw blood in resident #2’s brief and near theresident’s buttocks on the evening of 9/1/22. She said CNA A also saw the blood. LVN B she was not told someone was to be monitoring the halls prior to the incident on 9/1/22. She was aware of Resident #1 having a previous sexual incident but said he was not on any special supervision prior to 9/1/22.

During an interview on 9/4/22 at 1:43 p.m., NP E said she was the NP for Resident #1. She said she told the facility not to take Resident #1 back when he had gone to the behavior hospital in April 2022 due to his sexual behaviors. She said the nurse from the secure unit sent a fax to the office on 9/1/22 informing her of the incident with Resident #1 and #2. She said she saw the fax on 9/2/22. NP E said she was not scheduled to be at the facility on 9/2/22 but felt she needed to visit the facility to find out more about the incident. She said when she got to the facility, the DON told her nothing had happened between the residents. She said if the facility was not able to meet the needs of Resident #1. She said if the facility took him back, she would be giving the resident a 30-day discharge and he would need to find another physician.