ZEELAND, MI- SKLD ZEELAND

Based on interview and record review, the facility 1.) failed to ensure a comprehensive facility-wide assessment that included an assessment of the staffing needs, resident behaviors (wandering), resident acuity, and staff training and education requirements was complete and accurate, 2.) failed to evaluate the effectiveness of the interventions in place for residents with known behaviors, 3.) failed to identify increased behaviors and revise a care plan and 4.) failed to ensure there was sufficient staffing to supervise residents and prevent resident to resident abuse for 7 residents (Resident #9, #107, #32, #79, #24, #36, #1), resulting in a pattern of systemic neglect leading to resident to resident abuse and the decline in mental and psychosocial well-being.

Review of the Facility Reported Incident revealed that on 9/24/22 at 4:00 PM, (R107) was witnessed with his pants pulled down on top of (R9) while she was laying in her bed fully clothed (gown and brief on and not tampered with) her bed sheets were pulled up covering her body . (R107) was sent out to the hospital for evaluation . Through the investigation it was determined that prior to this event, (R107) did not display sexually inappropriate behavior toward other residents, he had historically directed his comments toward staff members and had been making comments throughout the day to staff members . Administrator spoke with (Family Member FM O), wife/guardian on 9/24/22 to inform her of the incident that occurred and his transfer to the hospital for further evaluation. At this time (FM O) stated that (R107) had no history of sexual behaviors towards other residents in the past and was surprised to hear of the incident . CONTRIBUTING FACTORS/ROOT CAUSE ANALYSIS: The primary root cause of (R107) sexually inappropriate behavior is due to his dementia and impaired ability to control impulsive behavior. In addition to the root cause, there are multiple contributing factors relating to the allegations: (R107) is diagnosed with schizophreniform disorder, dementia with behavioral disturbance, major depressive disorder, and restlessness/ agitation. (R107) had a medication change on 8/25/2022 and started on [MEDICATION(S)] for major depressive disorder, which was a new medication for him. (R107) recently had moved rooms . Indicating the facility identified possible agitators that caused an increase in R107’s behaviors and no new interventions were implemented prior to the incident.
During an interview on 12/01/22 at 04:07 PM, FM O reported that the incident never should have occurred. FM O reported that the facility wasn’t paying attention to this particular (dementia) unit and she could not understand how there were no staff supervising the residents, with known wandering behaviors, to prevent this type of situation. FM O stated, if they had been paying attention this wouldn’t have happened.

Review of R79’s Witness Statement dated 11/21/22 revealed, Last night around 2am-3am, I was lying down in bed on my back, he came in and said them are mine referring to my breasts. He grabbed my breasts over the top of my pajama shirt and bra. I screamed for the nurse, she came in and got him out. Then he came back about 20 min later. I yelled at him you can’t touch me, and I hit him on the head. I yelled for the nurse again and they took him out again .(R32) has been here too long, he goes in/out of rooms, he could rough anyone up at any time (interview with police officer) he came into my room [ROOM NUMBER] times last night. That man. (Could not provide a name or description after prompting from the officer). He said I want to feel you up and grabbed my breasts. I yelled Nurse, Nurse. Then he came back a second time and he grabbed them again and I yelled at him to get out and called for the Nurse. He didn’t say anything the second time when he grabbed me. Then he came in another time and I yelled at him to get out.

The facility investigation indicated a lack of supervision for R32 when it was known he was entering R79’s room. There were no immediate interventions put in place for R32’s behaviors after he entered R79’s room the first time causing R79 to be fearful and threaten physical violence against R32 when he attempted to enter her room the 2nd time. The FRI did not reflect that increased supervision or other interventions were implemented that would avoid psychosocial harm or physical abuse between R32 and R79. Additionally, the facility failed to affirm R79’s fearfulness resulting in mental anguish despite the nature of the allegation (unwitnessed sexual assault).

Review of the Facility Reported Incident for R36, R24, and R32 revealed, .On 10/13/2022 at 4:25 PM, staff witnessed resident (R36) in his room, using a walker to push resident (R32) away from him. Another resident, (R24) was also in the room at the time. (R36) stated when staff came in to assist, that he was trying to get (R32) and (R24) out of his room. (R36) said that (R24) took a swing at him .(R32) and (R24) have a history of wandering behavior due to their dementia diagnosis .(R36) was interviewed and gave an account for what happened in his room. He stated that (R24) took a swing at me and (R32) came down too, they were both in my room. He said that when (R24) took a swing at him, he said had no choice but to defend himself. He said he told them two times that they have to get out of here, that is when (R24) took a swing at him. (R36) said that he got (R24) away from him and then grabbed the walker that was in his room to put between himself and (R32) so he would not come near him .The root cause of the incident was (R24) and (R32) entering (R36’s) room. This caused (R36) to become upset with the gentlemen. When he asked (R36) to get out of his room that is what triggered (R24’s) response of, reportedly swinging at him