| 17 |
KENTMERE REHABILITATION AND HEALTHCARE CENTER |
85001 |
1900 LOVERING AVENUE |
WILMINGTON |
DE |
19806 |
2018-12-06 |
607 |
D |
1 |
1 |
H65F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of the clinical record, hospital record, facility and other documentation as indicated, it was determined that for one (R45) out of 54 sampled residents, the facility failed to develop and implement an abuse policy and procedure that addressed the requirements of the Federal Regulation 483.12(b). Specifically under the Protection requirement, the facility failed to have written procedures that ensured that all residents are protected from physical and psychosocial harm during and after the investigation. This must include: Responding immediately to protect the alleged victim and integrity of the investigation . The facility failed to protect R45 (alleged victim) and all residents when: - The allegation of sexual abuse was made on 11/7/18 and the facility began an investigation by obtaining written statements of those staff involved. However, the facility failed to immediately protect R45 as E7 (accused nurse) returned to R45's floor before leaving the facility on 11/7/18; and - The facility failed to protect all residents, including R45, when an investigation by law enforcement started on 11/21/18 and was ongoing as of 12/6/18 regarding the 11/7/18 allegation of sexual abuse against E7, a facility nurse. E7 remained on duty during the ongoing investigation, which allowed the accused nurse to have access to all residents, including R45. An immediate jeopardy situation was identified on 12/6/18 at 1:32 PM. Findings include: Cross refer to F580, F608, F609 and F610 The facility's policy entitled, Abuse, Neglect, Mistreatment, Misappropriation and Exploitation, effective (MONTH) (YEAR), stated, .Procedures: .5. Staff Responsibilities .b. If an act of abuse .is witnessed, the witness must act to first remove the source of the act, whether it is a staff member or a visitor, and then take steps to protect the resident . The facility failed to have written procedures as per the Federal Regulation requirement to ensure protection of all residents/alleged victim during and after the investigation. Review of R45's clinical record revealed: 10/2/18 - Review of a quarterly MDS assessment stated that R45 was severely cognitively impaired and had active [DIAGNOSES REDACTED]. 11/7/18 at 6:45 AM - An allegation of sexual abuse involving E7 (accused nurse) and a resident, R45, was reported by E10 (CNA) to E9 (RN, House Supervisor). E9 reported the allegation to E2 (DON), then E9 and E2 reported the allegation to E1 (NHA). E7 was requested to leave the floor to meet with E1 (NHA) and E2 (DON) on the ground floor where the facility management offices are located. E7 was then requested to write a statement. Once the allegation was made and facility's investigation started by obtaining written statements of those staff involved, the facility failed to protect R45 as E7 was allowed to return to R45's floor before leaving the facility on 11/7/18. The following events occurred after facility management was made aware and started their investigation: - At 8:07 AM, E7 documented a nurse's note in R45's electronic clinical record; - At 8:21 AM, E7 exited R45's floor according to E7's electronic swipe Card Activity History Report; - At 8:22 AM, E7 exited the facility. 11/8/18 at 10:04 AM - According to the facility's Incident Report submitted to the Delaware's Office of Long Term Care Resident Protection, the facility stated, .An internal investigation was conducted and completed and the allegation was found unsubstantiated. 11/8/18 between 9:45 AM-10:04 AM - F6 (R45's POA) stated, during a follow-up interview on 12/12/18 at 11:24 AM, that she asked if the facility called the local law enforcement agency to report the allegation of sexual abuse. It was not until after F1 (R45's family member) arrived at the facility at approx. 11:30 AM, met with E1 (NHA) and E2 (DON), F1 called F6 with an update, and it was at this point when R45's family (F1 and F6) insisted on a police report. 11/8/18 at 1:49 PM - According to the local law enforcement agency's dispatch records, the police were called at 1:49 PM. A police officer, F3, responded to the facility and met with E1 (NHA) and E2 (DON), whom informed F3 about the allegation and the facility's internal investigation findings, which were unsubstantiated. F3 left the facility without writing a report at 2:04 PM. 11/9/18 at 1 PM - A late entry nurse's note documented on 11/12/18 at 11:19 AM by E2 (DON) stated, After discussion with IDT, decided to send resident (R45) to ED for comprehensive exam .(F2, family member) called and in agreement with decision . 11/9/18 at 5:48 PM - According to the hospital record, R45 was seen and examined by the Emergency Department's Forensic Team. F4 (hospital Forensic Nurse) notified the local law enforcement agency and the State Survey Agency (at 5:53 PM) that R45 was seen and examined for an alleged sexual assault of adult. 11/21/18 at approx. 1 PM - According to email correspondence between F5 (Detective with the local law enforcement agency's Criminal Investigations Division) and E1 (NHA) and E2 (DON), F5 met with E1 and E2 at the facility about the 11/7/18 allegation of sexual abuse of R45. The facility provided F5 with requested facility documents, names and contact information for facility staff involved. The facility became aware that the 11/7/18 allegation of sexual abuse involving R45 and E7 (accused nurse) was being investigated by the local law enforcement agency's Criminal Investigations Division. 11/21/18 through 12/6/18 - The facility moved E7 (accused nurse) to a different floor from R45 after the 11/7/18 incident. Review of E7's Time Card Report revealed the accused nurse worked the following 11 PM to 7 AM shifts: - Friday, 11/23/18, into Saturday, 11/24/18; - Saturday, 11/24/18, into Sunday, 11/25/18; - Sunday, 11/25/18, into Monday, 11/26/18; - Monday, 11/26/18, into Tuesday, 11/27/18; - Friday, 11/30/18, into Saturday, 12/1/18; - Saturday, 12/1/18, into Sunday, 12/2/18; - Sunday, 12/2/18, into Monday, 12/3/18; and - Monday, 12/3/18, into Tuesday, 12/4/18. 11/21/18 through 12/6/18 - Review of the facility's staff posting revealed that E7 (accused nurse) worked as a floor nurse in addition to being the facility's House Supervisor on the following 11 PM to 7 AM shifts: - Saturday, 11/24/18, into Sunday, 11/25/18; - Friday, 11/30/18, into Saturday, 12/1/18; and - Saturday, 12/1/18, into Sunday, 12/2/18. Review of the facility's Nurse Supervisor policy, effective 5/16, stated, .Policy: To outline the duties and responsibilities of the Nurse Supervisor in compliance with State regulatory procedures .1. In compliance with State regulation, 2 hours of Registered Nurse (RN) time each shift (7-3, 3-11, 11-7), will be dedicated to administrative functions which include: - Rounds on units - Assisting with coverage/scheduling issues - Family concerns - Problem solving . 11/21/18 through 12/6/18 - Review of the facility's electronic swipe Card Activity History Report, which captured E7's assigned card access/exit to the floor where R45 was located, revealed the following dates and times: - 12/2/18 at 1:36 AM; - 12/2/18 at 2:20 AM; - 12/2/18 at 2:23 AM; - 12/2/18 at 6:44 AM; - 12/2/18 at 7:18 AM; - 12/3/18 at 6:52 AM. The facility became aware on 11/21/18 that the local law enforcement agency's Criminal Investigations Unit was investigating the 11/7/18 allegation of sexual abuse of R45 by E7. The facility failed to protect all the residents, including R45, during the investigation by allowing E7 to remain on duty, including assigning E7 as House Supervisor for 3 out of 8 shifts, giving E7 access to all residents, including R45, from 11/21/18 to 12/6/18. 12/5/18 at 2:10 PM - During an interview, E1 (NHA) stated that during the facility's investigation, the staffing schedule was checked to see if E7 (accused nurse) was off and E7 was. E1 stated otherwise, we would have had to suspend E7 or asked E7 not to come in until the facility finished their investigation. E7 was not scheduled to work until Saturday night, 11/10/18, on 11PM to 7AM shift. E1 stated that F5 (Detective from Criminal Investigations Unit) met with her and E2 (DON) and that F5 would notify her of the outcome of their investigation. E1 stated that she spoke with F6 (R45's POA) about not having E7 care for R45 and F6 agreed. E1 stated that E7 was assigned to a different floor from R45. E1 was asked by this surveyor if E7 had been House Supervisor on the 11PM-7AM shifts since the 11/7/18 incident, E1 said yes. 12/6/18 at 1:23 PM - E1 (NHA) and E2 (DON) was informed of an Immediate Jeopardy. 12/6/18 at 8:15 PM - The Immediate Jeopardy was abated. E1 (NHA) stated that R7 was placed on Administrative Leave until the conclusion of the criminal investigation. |
2020-09-01 |