| 1 |
JEFFERSON DAVIS COMMUNITY HOSPITAL ECF |
255050 |
1320 WINFIELD STREET |
PRENTISS |
MS |
39474 |
2017-07-26 |
225 |
D |
0 |
1 |
UP3C11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, the facility failed to ensure an unusual occurrence was reported and investigated to ensure serial exposure/abuse didn't occur, for one (1) of 10 sampled residents, Resident #5. Findings include: Review of the facility policy for Reporting Abuse to Facility Management, revised 2014, revealed it is the responsibility of employees and others to promptly report any incident or suspected incident of resident neglect or abuse to facility management. Sexual Abuse is defined as, but is not limited to, sexual harassment, sexual coercion , or sexual assault. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Service, or Charge Nurse .8. The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident. Review of the nurses notes revealed Resident #5 had been exhibiting new inappropriate sexual behavior starting 07/18/17, such as undressing, holding his penis in his hands and asking staff for sex. The nurse's notes dated 7/24/17 at 1:11 AM, 5:43 AM, and 5:50 AM, revealed Resident #5 had been found in two (2) female residents room taking his clothes off and looking at a female in the lobby with his penis in his hands saying come here. In an interview on 07/24/17, during the initial tour, Nurse #4 revealed that Resident #5 had a problem during the last night shift with undressing and going into two (2) female resident rooms. In an interview on 7/24/17 at 10:55 AM, RN #2 stated that Resident #5 had sexually inappropriate behavior during the night shift with staff and two (2) female residents. When asked if this was investigated or reported, RN #2 did not answer. RN #2 stated Resident #5 was in his room at this time awaiting discharge for his behavior. On 07/24/17 at 3:30 PM, Licensed Practical Nurse #1 was asked what happened with Resident #5 on the night shift. She revealed the resident had been found with his pants down standing outside of Resident #3's room and a little later Resident #6 called to ask nurse to come to her room because #5 was in her room. When asked if there was an incident report or investigation to determine if abuse had occurred, she stated the Administrator was made aware later that morning after she reported the incident. She further revealed the Direction of Nursing nor Administrator had been made aware during the night, and no investigation was initiated. Interview with RN #1, Abuse Coordinator, revealed she did not know why the sexually inappropriate behavior of Resident #5 wasn't reported during the night to the Administrator or DON as it should have been. Resident #5 was not available for interview or observation after the tour on 7/24/17, due to discharge related to behaviors. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/28/17, revealed Resident #5 scored 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. |
2020-09-01 |