| 75 |
DOVER CENTER FOR HEALTH & REHABILITATION |
305018 |
307 PLAZA DRIVE |
DOVER |
NH |
3820 |
2018-12-07 |
610 |
D |
1 |
1 |
9HC411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and facility policy review, it was determined that the facility failed to thoroughly investigate an alleged violation of abuse and to implement appropriate corrective actions to prevent further allegations of abuse for 1 resident in a standard survey sample of 22 residents. (Resident identifier is #41.) Findings include: Interview on 12/4/18 at approximately 11:30 a.m. with Resident #41 revealed that Resident #41 stated that a couple of weeks ago, they were inappropriately touched in their perineal area by a male staff member. Resident #41 stated that this male had also groped them several times since this original incident. While explaining the groping, Resident #41 was rubbing their chest area, indicating that it was their chest area that was groped. Resident #41 stated that this staff member was in their room last night and had groped their chest area again. Review on 12/4/18 of the Facility Report to the Long Term Care Ombudsman, dated 11/13/18, revealed that Resident #41 reported to therapy staff on 11/13/18 that they were assaulted by the male night staff. Resident #41 reported that .a man came in my room and was touching me inappropriately .Resident reported that he was not alone . The report revealed that staff member, Staff B (Licensed Practical Nurse) .was assisting with rounds. Staff B reported that (pronoun) had Staff D (Licensed Nursing Assistant) .assisting (pronoun) with rounds on this resident. They changed resident (sic) brief at this time . The Facility Report also revealed that Resident #41's care plan was reviewed and updated to have only female caregivers and two for ADL's (Activities of Daily Living.) Review on 12/6/18 of the Facility's investigation regarding the allegation made by Resident #41 revealed a statement, dated 11/13/18, which was written by Staff [NAME] (Director of Nursing) and had a verbal explanation given to Staff [NAME] by Staff B, the alleged perpetrator. In the statement, Staff B reported that on the 11-7 shift on 11/12/18 (the shift started at 11:00 p.m. on 11/12/18 and ended at 7:00 a.m. on 11/13/18) they were walking by Resident #41's room and saw Resident #41 ambulating by themselves. Staff B stated that they assisted Resident #41 back to bed. They stated that Staff C (Licensed Practical Nurse) heard them ask for assistance and Staff C immediately responded. Staff B reported that Resident #41 told Staff B to get out now. Staff B reported that they left at that time and did not provide personal care to Resident #41. There was nothing in the statement about the incontinent care that Staff B and Staff D had provided to Resident #41 earlier in the shift. Review on 12/6/18 of the Facility's investigation regarding the allegation made by Resident #41 revealed another statement. This statement was also written by Staff E, but signed and dated on 11/12/18, (Resident #41 did not report the incident to staff until 11/13/18) by Staff C. In that report, Staff C stated that Staff B was returning from break and saw Resident #41 walking by themselves. Staff B immediately got Staff C to assist Resident #41 back to bed. Staff B placed their hand on Resident #41's shoulder for assistance. The statement also revealed that Staff B was the only male staff member on 11/12/18 and was not alone in the room. Review on 12/6/18 of the Facility's investigation regarding the allegation made by Resident #41 revealed that there was no statement from Staff D. There was no evidence in the investigation file that Staff D was ever interviewed regarding the interaction that occurred when Staff B and Staff D changed Resident #41's brief. Interview on 12/7/18 at approximately 7:10 a.m. with Staff C revealed that Staff C stated that on 11/12/18, Staff B saw Resident #41 going to the bathroom by themselves and asked Resident #41 to wait for help. Staff B called out in the hallway but did not go in to Resident #41's room. Staff C took over and assisted Resident #41. Interview on 12/7/18 at approximately 7:15 a.m. with Staff B revealed that Staff B stated that they did not know anything about the incident on 11/12/18. Staff B reported that they were not even working on that night. Staff B denied having provided incontinent care to Resident #41 with Staff D. Staff B stated that the incident was not discussed with them by Staff [NAME] and that they knew that there were to be no male caregivers, but had only heard that through the grapevine a while later. Review of the Facility's Daily Attendance report revealed that Staff B did work from 10:45 p.m. until 7:15 a.m. on 11/12/18. Interview on 12/7/18 at approximately 10:10 a.m. with Staff D revealed that Staff D stated that on 11/12/18, they assisted Staff B, who was working as an LNA that night, to change Resident #41's incontinent brief. Staff D stated that later on in the shift, Staff D was told by Staff C that Staff B saw Resident #41 ambulating in their room by themselves. When Staff B called for assistance, Staff C responded and Staff C and Staff B assisted Resident #41 to the bathroom and provided care. Staff D reported that they had not been interviewed about anything that had occurred on 11/12/18 by any Administrative staff. They also stated they they were aware that there were to be no male caregivers, but only heard that through the grapevine about a week later, when they also heard that there was an allegation made by Resident #41. Staff D stated that they were not aware of how many staff were to care for Resident #41. Review on 12/6/18 of Resident #41's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration and Treatment Administration Records revealed that there was documentation that Staff B checked placement of Resident 41's [MEDICATION NAME] on 11/26/18, on 12/3/18 with the documented placement on Resident #41's chest, and on 12/4/18 with the documented placement on Resident #41's chest. Review on 12/6/18 of Resident #41's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration and Treatment Administration Records revealed that there was also documentation that another male staff member, Staff F (Licensed Practical Nurse,) performed procedures on Resident #41. The documentation revealed that Staff F applied barrier cream to Resident #41's buttocks on 11/16/18, 11/19/18, 11/23/18, 11/24/18, and 11/25/18, Staff F did a skin check on Resident #41 on 11/19/18. Staff F also checked [MEDICATION NAME] placement on Resident #41 on 11/25/18, cleansed a wound on Resident #41's right knee on 11/23/18, removed compression stockings on Resident #41 on 11/16/18, 11/19/18, 11/23/18, 11/24/18, 11/25/18, and 12/4/18, and applied warm compresses to Resident #41's right knee on 11/16/18, 11/19/18, 11/23/18, 11/24/18 and 11/25/18. Review on 12/6/18 of the Facility's Policy titled Abuse, revised on 3/18, revealed that The administrative staff .assumes responsibility for .Immediate investigation into the alleged incident .Interview staff member implicated. Have employee document their knowledge/version of incident in written narrative that is dated and signed Interview witnesses or other available witnesses. Witnesses are to document incident in a written narrative that is dated and signed. Supervisory staff to discuss written statements with employee . Facility investigation will be completed within 72 hours of the incident .Immediately after the incident occurs an interim conference is to be held to develop interventions to ensure the resident does not experience any physical harm, pain or mental anguish . Interview on 12/7/18 with Staff [NAME] confirmed that the facility policy for an investigation was to get statements from all staff involved. If they were unable to get a written statement, they would get a verbal one, which was followed up by a written statement, dated and signed, as soon as possible. Staff [NAME] confirmed that there were no statements written by Staff B or Staff C and that there was no statement at all for Staff D. Staff [NAME] also confirmed that Staff B did work on the night of 11/12/18 and did provide incontinent care to Resident #41 with Staff D, earlier in the shift before Resident #41 was found ambulating independently in their room. Staff [NAME] also confirmed that as part of the follow up plan, no physical care to Resident #41 should have been provided by male staff. Staff [NAME] stated that there were always female nurses in the building and that male staff could always get a female to perform the tasks and to document them. |
2020-09-01 |