Consulate Health Care of Jacksonville 02-17-2015

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED:2/13/2018
CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED

OMB NO. 0938-0391
STATEMENT OF (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
DEFICIENCIES / CLIA A. BUILDING ______ COMPLETED
AND PLAN OF IDENNTIFICATION B. WING _____ 02/17/2015
CORRECTION NUMBER
105917
NAME OF PROVIDER OF SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CONSULATE HEALTH CARE OF JACKSONVILLE 4101 SOUTHPOINT DRIVE EAST
JACKSONVILLE, FL 32216
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0157 Immediately tell the resident, the resident's doctor and a family member of the resident
of situations (injury/decline/room, etc.) that affect the resident.
Level of harm - Minimal
harm or potential for actual Based on staff interviews and record review, the facility failed to immediately notify the physician and family following a
harm reported incident of sexual contact between one cognitively impaired resident (Resident#1) and another resident (Resident
#2), out of 5 residents reviewed for neglect and abuse.
Residents Affected - Few The findings include:
A review of the medical record for Resident #1 revealed a nursing note, dated 02/09/2015, at 13:40 hours that read, Writer
observed resident giving oral sex to another resident. Writer immediately stopped both residents and separated them. Proper
supervisor as well as Social Services was notified. Social Services will notify families of incident. Resident is alert
with dementia. Resident has to be redirected at times. Wanders throughout the facility. Resident has WanderGuard® (a
signaling device that alarms when the resident exits the property) in place. Resident tolerated meds well today. No SOB
noted. Denies pain. Resident will be monitored closely. The note was signed by Employee A, Licensed Practical Nurse.
Further review of the medical record for Resident #1 revealed no evidence that her physician had been not been notified of
the incident. No new orders were found.
In an interview on 2/12/2015 at 2:35 pm with the Administrator and the Director of Nursing (DON), who was the Abuse
Coordinator, the DON stated after reading Employee A's nursing note about the incident, I went down and interviewed both
residents and they denied it ever happened. She was asked, Was there any investigation into this? She stated, Why would
there be? They are both alert and oriented consenting adults.
An interview with the DON on 2/13/15 at 5:22pm revealed that she reviewed the medical record for Resident #1 and stated that
there was no documentation of a skin assessment, or that the physician was notified of the 2/9/15 incident.
An interview with Employee A on 02/16/2015 at 10:02 am revealed when asked if she was told by her supervisors to complete a
full physical examination of Resident #1 or notify the resident's doctor, she stated, No, I was told that nothing else
needed to be done. I asked if I needed to fill out any forms or write a statement and I was told that 'nothing more can be
done', so I went back to the floor.
A phone interview with Resident #1's physician was conducted on 2/17/15 at 11:40 am. He stated he was not sure what date he
was notified about the incident that occurred on 02/09/2015 between Resident #1 and Resident #2. He stated that he thought
he was verbally told about it on 2/11/15. He stated he was asked on Friday, 02/13/2015, to examine Resident #1. He
apologized and stated he wasn't sure saying My memory is not good for these things sometimes. He stated that he should have
been notified by the facility on 02/09/2015 that the incident had occurred.
In an interview on 2/12/2015 at 12:25 pm with the Social Services Director (SSD), she stated that she called the families of
Residents #1 and #2 after the incident on 2/09/2015. She stated she left a message for Resident #1's daughter, but she had
not heard from her yet. She stated that she had not tried to contact the secondary family member that was listed in
Resident #1's record (the resident's son). The SSD said she has had no further involvement in this case.
F 0224 Write and use policies that forbid mistreatment, neglect and abuse of residents and theft
of residents' property.
Level of harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
jeopardy Based on observation, resident interviews, staff interviews, and record review, the facility's abuse policies failed to
prohibit sexual abuse of 1 resident (Residents #1), out of 5 residents reviewed for abuse. The facility had knowledge that
Residents Affected - Few Resident #1, who was severely cognitively impaired, exhibited sexualized behaviors toward Resident #2. The facility did not
report these behaviors to Resident #1's psychiatric provider, or protect the resident from Resident #2, who was at a much
higher level of cognitive function. The facility also had knowledge that an employee reported an allegation of sexual abuse
involving residents #1 and #2 on February 9, 2015, but failed to investigate the allegation of abuse and ensure that
Resident #1 was protected from the alleged perpetrator from 02/09/2015 to 02/13/2015.
After the staff member's allegation, the alleged abuser continued to reside in the same location within the facility and to
have unencumbered access to Resident #1 from 02/09/2015 through 2/13/2015 at approximately 1:00 pm, when both residents
were put on one-to-one supervision. This resulted in Immediate Jeopardy beginning on 2/09/2015. The facility's failure to
prevent and investigate physical abuse, protect the victim, and monitor the alleged abuser, placed residents in the
facility who were cognitively impaired at risk for serious injury, harm, or impairment.
Immediate Jeopardy was ongoing on exit on 2/17/15.
Substandard quality of care was identified at F-224 (S/S J). Cross reference to F-225 (S/S J), F-226 (S/S J), and F-323 (S/S
J).
The findings include:
A complaint survey was conducted at the facility on 02/12/2015 at 9:10 am. The anonymous complaint alleged facility failure
to prevent and investigate an incident of resident to resident sexual abuse. A review of the medical record for Resident #1
revealed a nursing note, dated 02/09/2015 at 1:40 pm, that read, Writer observed resident giving oral sex to another
resident (Resident #2). Writer immediately stopped both residents and separated them. Proper supervisor as well as Social
Services was notified. Social Services will notify families of incident. Resident (#1) is alert with dementia. Resident
(#1) has to be redirected at times. Wanders throughout the facility. Resident (#1) has WanderGuard® (a signaling device
that alarms when the resident exits the property) in place. Resident tolerated meds (medications) well today. No SOB
(shortness of breath) noted. Denies pain. Resident will be monitored closely. The note was signed by Employee A, Licensed
Practical Nurse (LPN).
In a telephone interview on 2/12/2015 at 4:28pm with Employee A, she stated that on 2/09/2015, at approximately 1:20 pm, as
she was walking down the hall and passed by Resident #1's room, she glanced into the room and saw a man with his pants
down, standing next to the bed nearest to the window. She stated she knew that was Resident #1's bed, and she became
alarmed. Employee A stated that she went into the room and saw Resident #1 lying in her bed on her left side, facing
Resident #2. Resident #1 was supporting herself on her elbow, and had her hand on Resident #2's penis in her mouth.
Employee A stated in the interview, I saw it happening. I physically saw it. I know what I saw. She stated she immediately
told the residents to stop, and for Resident #2 to leave the room. She stated she went to the nurses' station and
immediately reported the incident to the Unit Manager (UM). She stated that the UM told her to report the incident to the
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

REPRESENTATIVE'S SIGNATURE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Event ID: YL1O11 Facility ID: 105917 If continuation sheet
Previous Versions Obsolete Page 1 of 12
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CORRECTION NUMBER
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F 0224 (continued... from page 1)
Director of Nurses (DON) right away. Employee A stated that she then spoke with the Social Services Director (SSD) about
Level of harm - Immediate the incident, and they both reported it to the DON. Employee A stated that the DON treated her like she was lying about
jeopardy what she saw, and told her and the SSD that nothing could be done about the incident, because the residents were consenting
adults. Employee A stated that she told the DON that Resident #1 was not able to consent because she had advanced senile
Residents Affected - Few dementia, and she was not as high functioning mentally as Resident #2. She stated that she told the DON that she was afraid
that Resident #2 may have and would continue to take advantage of Resident #1. She stated that the facility should not
allow this to happen even if it appeared that Resident #1 was not harmed.
In an interview on 2/13/15 at 1:30pm with the SSD, she said that she told the DON that she had interviewed both residents,
and that both were denying the allegation. The SSD said that Employee A then told the DON again that she saw the incident,
and she was sure of what she saw. The DON asked if anyone else saw it, and Employee A told her she didn't think so. The SSD
stated that the DON then said that both residents were consenting adults. The SSD stated at the time of the interview that
she did not believe Resident #1 was a consenting adult.
In an interview with Employee D, CNA, on 2/13/15 at 3:05pm she stated that on 02/09/2015, she was right there at Resident
#1's room at the time that Employee A said she saw Residents #1 and #2 involved in oral sex in Resident #1's room. Employee
D stated that she saw Resident #2 with his hands on his pants. She couldn't see what he was doing. His pants were up.
Resident #1 was fully dressed and facing Resident #2. She stated that she followed Employee A to the nurses' station, and
overheard Employee A tell the UM that the two residents were having sex.
In an interview with Employee B, LPN, on 02/13/2015 at approximately 2:48 pm, she stated that she has worked at the facility
since March, 2014, and she is assigned regularly to Resident #2. She stated that she was caring for Resident #2 on 2/9/15,
when Employee A told her at approximately 1:30 pm that she just witnessed the two residents having oral sex in Resident
#1's room. Employee B stated that earlier that same day (02/09/2015), she saw Resident #1 sitting on Resident #2's bed. She
said that Resident #2 was fully dressed and he was lying on his bed. Resident #1 was seated on the bed at the foot of the
bed. Employee B stated that she saw Resident #1 rubbing Resident #2's pants leg near his ankle. Employee B said that she
told Resident #1 to come out of the room. Employee B was asked if she reported this observation to anyone, and she stated
she had not. She added, Everybody knows how they are, them two. Sometimes she is seen rubbing his back. She stated, It's
common knowledge that she will come up to him and touch him.
In an interview on 2/13/15 at 4:35pm with the UM, she stated that on 2/9/15 at an unknown time, Employee A reported
observing two residents having oral sex. The UM said that she instructed Employee A to report the incident to the DON. The
UM said that when Employee A returned to the floor, Employee A said that the DON told her that both residents were alert
and oriented, and nothing needed to be done. The UM told Employee A to document everything in the resident's record. The UM
stated that she was not instructed by the DON to do anything more about this incident. When asked, the UM stated that she
didn't think Resident #1 was capable of making decisions regarding sex. She stated that Resident #1 was confused, and that
was probably why the incident happened. She stated that Employee B did not report to her on 2/9/15 that Resident #1 had
been in Resident #2's room earlier in the day. She stated that she did not call the abuse hotline about the incident
because she thought the DON would do it. She stated that she did not know if Resident #1's physician had been notified of
the incident. She reviewed Resident #1's record and stated that the resident had not been examined since the incident.
Record review revealed that Resident #1 resided in room [ROOM NUMBER]W. She was [AGE] years old and admitted to the facility
on [DATE], with [DIAGNOSES REDACTED]. The record also showed a [DIAGNOSES REDACTED]. The resident was prescribed
[MEDICATION NAME] 50mg twice a day for [MEDICAL CONDITION] disorder, [MEDICATION NAME] 50mg daily for
depression, and
[MEDICATION NAME] XR 28mg daily for dementia. The resident's daughter signed the resident's consents for treatment.
Review of the Minimum Data Set (MDS), dated [DATE], revealed in Section C, Cognitive, that Resident #1 had a Brief Interview
for Mental Status (BIMS, to determine the individual's attention, orientation and ability to register and recall new
information) with a score of 5 (severe impairment) out of a possible 15. She was assessed as not being oriented to year,
month, or day, and could recall two out of three items after being cued. She continuously had difficulty focusing her
attention, and had disorganized thinking with no fluctuation. Section D, Mood, revealed that Resident #1 had trouble
concentrating on things, such as watching television or reading a newspaper. She had behavior of restlessness or moving
around more than usual during half or more of the days of the assessment period.
Record review for Resident #2 revealed that he was [AGE] years old, and admitted to the facility on [DATE] with [DIAGNOSES
REDACTED]. The record noted a short term memory problem, alert to person and place, independent in cognitive decision
making, makes self understood, and no confusion. Issues assessed at his 1/20/15 neurology appointment included [MEDICAL
CONDITION] ([MEDICAL CONDITION] caused by a blow to the head) and erectile dysfunction.
Review of Resident #2's safety care plan, original date 4/1/14 and latest revision date 12/31/14, revealed problems of
removes his WanderGuard® and continues to go outside unattended, and refuses smoking policy. There were no interventions
listed for these behaviors. Also listed (no date) as a problem on the care plan was the statement, Resident has had sex
acts performed on him by female resident. The intervention listed stated, Attempt to redirect if found in sex act with
another resident, provide privacy if both residents in agreement.
Review of the facility map revealed that Resident #2's room, #300A, was located at the beginning of the 300 hallway next to
the nursing station. Resident #1's room, 204W, was on the next hallway that began at the nursing station, about 4 doors
down the 300 hallway.
In an interview on 02/12/2015 at 5:08 pm with the DON, when asked how she determined that Resident #1 was a consenting
adult, she stated that Employee A and the SSD told her that the resident was sometimes confused, but she was alert and
oriented. The DON added that the resident was able to carry on a conversation, and sometimes converts to Spanish. The DON
said that when she interviewed Employee A, she asked her if both residents were alert and oriented, and Employee A told her
they were. She stated that the SSD then left the room to interview both residents involved, the nurse went back to the
floor, and that was the end of it. The DON stated that she was not aware of any incident between the two residents earlier
in the day. She stated that law enforcement had not been informed of the incident.
In an interview on 2/13/2015 at 1:30 pm with the SSD, she stated that she thought the incident happened between 1:00 pm and
2:00 pm on 2/9/15. She stated she received a frantic phone call from the UM on the long term care unit, asking her to come
to the unit. She stated that when she got to the unit the UM told her that Employee A had reported that she saw Resident #1
and Resident #2 having oral sex. The SSD said she went directly to Resident #2's room and interviewed him. She said she
asked him about an incident that just happened and he told her, I did not do that. You believe everything everybody else
tells you. The SSD's progress note dated 2/9/15 at 2:35pm stated that Resident #2 became upset about this writer not
believing him. The SSD asked Resident #2 if he was in another resident's room, and he stated he wasn't. The SSD said that
Resident #2 started to become agitated with her, so she thanked him and went to Resident #1's room.
The SSD stated that she found Resident #1 sleeping on her bed. The SSD tapped the resident on the shoulder and woke her up.
The SSD asked the resident about the incident that just happened. Resident #1 denied that a man was in her room, or that
the incident occurred.
In an interview on 2/12/2015 at 12:25 pm with the SSD, she stated that she called the families of Residents #1 and #2 after
the incident on 2/09/2015. She stated she left a message for Resident #1's daughter, but she had not heard from her yet.
She stated that she had not tried to contact the secondary family member that was listed in Resident #1's record (the
resident's son). She stated she was not told to do any investigation into this incident. She stated that the DON would be
the one to investigate, since she was the Abuse Coordinator. The SSD said she has had no further involvement in this case.
In an interview on 2/12/2015 at 2:35pm with the Administrator and the DON, the DON stated after the reading Employee A's
nursing note about the incident dated 2/09/2015, I went down and interviewed both residents and they denied it ever
happened. She was asked, Was there any investigation into this? She stated, Why would there be? They are both alert and
oriented consenting adults. When informed by this surveyor that Resident #1 was cognitively impaired with a BIMS score of 5
out of a possible 15, the DON made no reply. The DON was asked if anything was done to protect the residents in the
facility since the incident, such as moving one of the residents to a different location, or changing the supervision of
the residents; She stated, No. She stated she did not investigate the allegation because she was informed that both
residents were consenting adults. When the administrator read the nurse's note about the incident, he stated, I didn't know
anything about this.
An interview with Employee A on 02/16/2015 at 10:02 am revealed that when asked if she was told by her supervisors to call
the State abuse reporting hotline, or notify the residents' doctors, she stated, No, I was told by the DON that nothing
OMB NO. 0938-0391
CORRECTION NUMBER
105917
else needed to be done. I asked if I needed to fill out any forms or write a statement, and I was told that 'nothing more
Level of harm - Immediate can be done', so I went back to the floor.
jeopardy Interview on 2/12/15 at approximately 3:10 pm with the Administrator revealed that he was very disappointed that the
incident had not been brought to his attention. He stated he had already instructed the DON to begin an investigation. He
Residents Affected - Few stated, I asked (the DON), what were you thinking? Why didn't you report this? He stated he would have reported and
investigated this incident if he had known.
Review of the Federal Report for abuse dated 2/12/15, the incident was reported to the Florida abuse registry on 2/12/15 at
5:52pm.
Resident #2 was observed on 02/12/2015 at 11:15 am ambulating, without use of an assistive device, off of the long term care
unit. He returned a few minutes later and got a wheelchair and pushed it off the unit toward the dining room. He was
observed at approximately 11:35 am seated in his wheelchair, backing it up in front of the nurses' station. The resident
did not interact with staff or other residents during the observations. He was not being supervised.
Residents #1 and #2 were both observed in the main dining room from approximately 2:20 pm until 2:50 pm on 02/12/2015. Both
residents were observed to be dancing to music being played by a male entertainer hired by the facility to provide music
for the residents. Facility staff was present in the dining room and the hallway outside the dining room. Residents #1 and
#2 were not on one-to-one supervision, and had access to each other. Both came and went from the dining room without
supervision.
An interview with Resident #2 on 2/12/2015 at approximately 4:05 pm revealed that he spoke English with a very thick accent,
and he was alert and oriented to person, place, time, and circumstance. He was pleasant and appeared well groomed and
appropriately dressed. He stated he was not interested in Resident #1 because she was too old for him. When asked if he
would be interested in younger women, he said, Yes, but he was in this place, a hospital. He stated that he could not have
erections since his accident, so there was no way he could have been with Resident #1. He stated, It doesn't work down
there. He pointed toward his crotch. He was asked if he was in Resident #1's room on Monday, and if the nurse came in and
told him to leave. He stated, I go down and around her room but I don't go in. He said that the nurse who made the
allegation talks too much, while at the same time, he made duck quacking gestures with his hands. He repeatedly stated he
had problems having erections since his accident, and the incident could not have happened.
An interview on 02/13/2015 at 2:35 pm with the psychiatric Advanced Registered Nurse Practitioner (ARNP) revealed that the
facility called her on 2/12/15 to consult on Resident #2 regarding the 2/9/15 incident. She stated that Resident #2 denied
anything regarding the allegation. The ARNP stated that she sees Resident #1 on a regular basis, and she (the ARNP) doesn't
think Resident #1 could consent to having sex. Review of the ARNP's progress note for Resident #1 dated 2/16/15 revealed
that the resident had slow thought processes, poor insight/judgment, was well oriented to person only, had impaired memory
and delusions. The ARNP documented that the sexual incident was reported to her on 2/13/15. When the ARNP interviewed
Resident #1 on 2/16/15, she denied knowing anything about the incident. The note stated that staff reported Resident #1 has
been seen on other occasions acting inappropriately in a sexual manner. The ARNP documented that she had not seen or had
other reports before now.
Review of the ARNP's progress note for Resident #2 revealed that he was examined on 2/13/15. His behavior and thought
processes were normal, insight/judgment were adequate, he was oriented to person, place, and time, his memory was intact,
and his mood was normal.
In an interview with Resident #3 on 2/16/15 at 3:01pm, when asked whether she had seen any residents behave in a sexually
inappropriate manner, she said that Resident #1 walks around and likes to mess with men. She said that Resident #1 twists
in front of everybody and sits on their laps. She said that staff try to get her up and away, but she doesn't know any
better.
During an interview with Employee C, Certified Nursing Assistant (CNA), on 02/13/2015 at approximately 2:58 pm, she stated
that she worked full time on the 7a-3p shift, and she was familiar with Resident #1. Employee C stated that at times
Resident #1 is confused, and she has to re-direct her. She stated that Resident #1 is social in the dining room, and she
gravitates to Resident #2. Employee C said that resident #1 is touchy with Resident #2. She stated, She dances in the
dining room, and when he's around she acts like she wants to do more with him. She stated she took care of Resident #2 when
he was first admitted on the short term rehabilitation unit, and she described him as flirty. She stated she saw Resident
#2 taking Resident #1 out the back hallway one day toward the smoking area. She stopped Resident #1 from going with him.
She stated that Resident #2 knows the code for the back door. She explained that the alarm for Resident 1's WanderGuard®
only goes off at the front door. She stated she thinks that Resident #1 wears a WanderGuard®. When asked, Employee C stated
that she didn't think Resident #1 could consent to sex.
Employee C stated that Residents #1 and #2 were not on one-to-one supervision this morning (2/13/15). She stated, They did
not put them on one-to-one until after I got back from lunch. She thought it was around 12:30pm. She stated that there were
two CNAs assigned to be one-to-one with the two residents now. Regarding re-training for abuse, Employee C stated that she
was not in-serviced, but at around 2:30pm today she was asked to sign a one page paper showing that she had received
education on abuse today.
During an interview on 2/13/15 at 3:05pm with Employee D, CNA, she stated that she worked the 7a-3pm shift on the 200 hall,
and she was usually assigned to Resident #1. She stated, She's sweet. She's a little promiscuous. She likes to shake her
bootie a lot. Every now and then, I catch her kissing somebody. She stated that she has seen Resident #1 gravitate toward
Resident #2. She stated that Resident #1 loves men. Employee D stated that Resident #1 liked another resident in the past,
but the man's wife got upset with the attention Resident #1 was paying to her husband. The staff made sure that Resident #1
didn't go near that resident anymore. Employee D stated that Resident #1 usually goes into Resident #2's room. She stated
that when she sees her go in the room, she goes to get her.
Employee D stated that when Resident #2 first got moved to the long term care unit, he was flirtatious with her and would
try to kiss her hands. She corrected him and she hasn't had a problem with him since. She was asked if she thought Resident
#1 was able to consent to sex with Resident #2, and she stated that she didn't think so.
When asked about re-training for abuse, Employee D stated that the Assistant Director of Nursing (ADON) gave her education
on abuse today. There were 5 staff members in the group. The ADON explained about sexual abuse, and to separate the
residents if found having sex. She stated the ADON had her sign a form today saying she'd been educated about abuse.
Review of the care plan for Resident #1 dated 1/13/2015 revealed that the resident was not care planned for any of the
sexualized behaviors observed by staff. A hand written note, dated 02/10/2015, on the resident's Behavior care plan
indicated the resident makes sexual gestures, is exit seeking, rummages, and is physically inappropriate (performs sex acts
on male resident). In the Approaches and Interventions column of the plan, a hand written update, dated 2/10/2015, read,
Attempt to redirect if found performing sex act, but provide privacy if residents are both in agreement.
During an interview with Employee E, CNA, on 02/13/2015 at approximately 3:10 pm, she stated that she had worked at the
facility for 2.5 years and she has been assigned to Resident #2. She stated that Resident #2 was pleasant and very
independent. She said that he keeps to himself, Skypes (live audio and visual communication via internet connection) with
his sister on the computer, asks for the things he needs, and goes out to smoke and chat with other smoking residents. She
was asked if she knew Resident #1, and she stated that she did, adding that Resident #1, Walks the hallways and goes into
every room; She's like a butterfly. She doesn't understand that she shouldn't be in other peoples' rooms. Her mind set is
like she's fifty. She touches people on the shoulders. Some residents complain about it. She touches males and females.
She's very easy to like. She stated she didn't think that Resident #1 could give consent to have sex. Employee E stated
that Resident #1 had a WanderGuard® alarm on, and when she goes out the doors someone goes out and gets her. She stated she
got abuse training today from the ADON around 2:15 pm - 2:30 pm. She stated she was told to read a piece of paper with
information on abuse, and asked to sign it. She said that the training took approximately 5 minutes.
During an interview on 02/13/15 at 5:00 pm with the MDS Coordinator, she stated that she attended morning meetings on
2/10/15 - 2/12/15, and there was no discussion at the meetings about the incident involving Resident #1 and Resident #2.
She stated that the DON informed her on 2/13/15 that there had been a sexual incident between the two residents, and she
was to update the care plan. She said the DON told her exactly what to write on the care plans.
In an interview conducted on 2/13/15 at 5:22pm with the DON she reviewed Resident #1's medical record and stated that there
was no documentation of an assessment of Resident #1 after the incident, or that her physician was notified. She was asked
if both should have been done, and she stated that they should have been. The DON confirmed that she had not conducted
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interviews of all facility staff involved in the incident. She stated that she completed an incident report on 2/12/15
Level of harm - Immediate regarding the incident, and sent it to the facility's corporate office. She could not produce a copy of the report for
jeopardy review. The administrator stated that he had not reviewed the incident report prior to it being sent through the mail to
the corporate office. The DON told the surveyor, I should have investigated, and I take responsibility for that.
Residents Affected - Few A phone interview with Resident #1's physician was conducted on 2/17/15 at 11:40 am. He stated he was not sure what date he
was notified about the incident that occurred between Resident #1 and Resident #2 on 02/09/2015. He stated that the
earliest date he could recall being told about it was on 2/11/15. He stated he was asked on 2/13/15 to examine Resident #1.
He stated that staff should have notified him on 02/09/2015 about the incident.
Review of the physician progress notes [REDACTED].
In an interview with Employee F, CNA, on 2/13/15 at 4:00pm she stated that she thought she got education about abuse today,
but she wasn't sure. She said it lasted a couple of minutes. She said she signed her name, but she wasn't sure what it was
because she was walking with a resident. She stated she really didn't have time to read it.
Review of the Resident Abuse policy and procedure, dated 11/30/2014, revealed that the policy defined sexual abuse as
including sexual harassment, sexual coercion, sexual assault or allowing a resident to be sexually abused by another, and
inciting any of the above. The policy stated, Furthermore, the Administration of The Company recognizes that resident abuse
can be committed by other residents, visitors, or volunteers. The Employee Obligation section read, All employees have a
duty to respect the rights of all residents, to treat them with dignity, and to prevent others from violating their rights.
Any employee who witnesses or has knowledge of an act of abuse to a resident is obligated to report such information to the
Clinical Nurse in charge, Director of Clinical Services, and the Executive Director. The policy did not mention the
individual obligation of all staff who witness abuse to report to state authorities.
The Identification of Abuse section stated that the Abuse Coordinator or his/her designee shall investigate all reports of
suspected abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse
Coordinator and an abuse investigation will be conducted. In the absence of the Executive Director, the Director of
Clinical Services will serve as Abuse Coordinator.
The Preliminary Investigation section stated that immediately upon report of an incident to the individual in charge, the
suspect shall be segregated from the resident. The policy did not address protecting all residents from the alleged abuser.
The policy stated that the Clinical Nurse in charge or the Director of Clinical Services shall perform and document a
thorough nursing assessment, and notify the attending physician. The policy did not specify when this should be done. The
policy stated that an incident report shall be filed as soon as possible in order to provide the most accurate information
in a timely fashion.
The Procedure for Reporting Abuse section read, All incidents of resident abuse are to be reported immediately to the
Clinical Nurse in Charge, Director of Clinical Services, and the Executive Director. Once reported to one of the three
officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an
investigation. The policy then stated that the abuse coordinator is responsible for reporting to appropriate officials in
accordance with Federal and State Regulations. The policy did not mention the obligation of all staff who witness abuse to
report to state authorities.
The Investigations section read, The Abuse Coordinator and/or Director of Clinical Services shall take statements from the
victim, the suspect(s), and all possible witnesses, including all other employees in the vicinity of the alleged abuse.
He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared.
The Discipline section read, The Abuse Coordinator of The Company will refer any or all incidents and reports of resident
abuse to the appropriate state agencies.
There was no mention in the facility's abuse policy of notification of law enforcement.
The facility's handout titled Freedom From Abuse Notice To Employees, used by the facilty in re-training of staff commencing
on 2/13/15, described the following reporting structure for staff in the event of suspected or observed abuse: Executive
Director, Vice President of Human Resources, Medical Director, Director Of Clinical Services, Ombudsman, and all other
officials required by law. This document did not mention sexual abuse, and did not include notification of law enforcement
or the abuse coordinator.
F 0225 1) Hire only people with no legal history of abusing, neglecting or mistreating
residents; or 2) report and investigate any acts or reports of abuse, neglect or
Level of harm - Immediate mistreatment of residents.
jeopardy **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, resident and staff interviews, and record review, the facility failed to report and investigate the
Residents Affected - Few sexual abuse of one resident who was cognitively impaired (Resident #1), out of 5 residents reviewed for allegations of
abuse or neglect. The facility had knowledge that an employee reported witnessing a sexual act between Resident #1 and
Resident #2 on February 9, 2015, but failed to investigate the allegation of abuse or report it to the Administrator. In
addition, the facility failed to ensure that Resident #1 was protected from the alleged perpetrator (Resident #2) after the
sexual act was observed. Resident #2 continued to reside in the same location within the facility and to have unencumbered
access to Resident #1 and all other residents in the facility from 02/09/2015 through 2/13/2015 at approximately 1:00 pm,
when both Residents #1 and #2 were put on one to one supervision. The facility also failed to identify and act upon
sexualized behaviors exhibited by Resident #1 that placed her at risk for abuse. This resulted in Immediate Jeopardy
beginning on 2/09/2015. The facility's failure to prevent and investigate an incident of sexual abuse, and protect
residents from the alleged abuser, placed cognitively impaired residents in the facility at risk for serious injury, harm,
or impairment.
Substandard quality of care was identified at F-225 (S/S J). Cross reference F-224 (S/S J), F-226 (S/S J), and F-323 (S/S J).
A review of the medical record for Resident #1 revealed a nursing note, dated 02/09/2015 at 1:40 pm, that read, Writer
observed resident giving oral sex to another resident (Resident #2). Writer immediately stopped both residents and
separated them. Proper supervisor as well as Social Services was notified. Social Services will notify families of
incident. Resident (#1) is alert with dementia. Resident (#1) has to be redirected at times. Wanders throughout the
facility. Resident (#1) has WanderGuard® (a signaling device that alarms when the resident exits the property) in place.
Resident tolerated meds (medications) well today. No SOB (shortness of breath) noted. Denies pain. Resident will be
monitored closely. The note was signed by Employee A, Licensed Practical Nurse (LPN).
the incident, and they both reported it to the DON. Employee A stated that the DON treated her like she was lying about
what she saw, and told her and the SSD that nothing could be done about the incident, because the residents were consenting
dementia, and she was not as high functioning mentally as Resident #2. She stated that she told the DON that she was afraid
OMB NO. 0938-0391
CORRECTION NUMBER
105917
Level of harm - Immediate and she was sure of what she saw. The DON asked if anyone else saw it, and Employee A told her she didn't think so. The SSD
jeopardy stated that the DON then said that both residents were consenting adults. The SSD stated at the time of the interview that
Residents Affected - Few In an interview with Employee D, CNA, on 2/13/15 at 3:05pm she stated that on 02/09/2015, she was right there at Resident
Resident #1 was fully dressed and facing Resident #2. She stated that she followed Employee A to the nurses' station, and
depression, and
The SSD asked the resident about the incident that just happened.
In an interview on 2/12/2015 at 12:25 pm with the SSD, she stated she was not told to do any investigation into this
incident. She stated that the DON would be the one to investigate, since she was the Abuse Coordinator. The SSD said she
has had no further involvement in this case.
can be done,' so I went back to the floor.
Interview on 2/12/15 at approximately 3:10 pm with the Administrator revealed that he was very disappointed that the
stated, I asked (the DON), what were you thinking? Why didn't you report this? He stated he would have reported and
5:52pm.
OMB NO. 0938-0391
CORRECTION NUMBER
105917
Level of harm - Immediate Residents #1 and #2 were both observed in the main dining room from approximately 2:20 pm until 2:50 pm on 02/12/2015. Both
jeopardy residents were observed to be dancing to music being played by a male entertainer hired by the facility to provide music
Residents Affected - Few #2 were not on one to one supervision, and had access to each other. Both came and went from the dining room without
supervision.
better.
regarding the incident, and sent it to the facility's corporate office. She could not produce a copy of the report for
review. The administrator stated that he had not reviewed the incident report prior to it being sent through the mail to
OMB NO. 0938-0391
CORRECTION NUMBER
105917
Level of harm - Immediate Any employee who witnesses or has knowledge of an act of abuse to a resident is obligated to report such information to the
jeopardy Clinical Nurse in charge, Director of Clinical Services, and the Executive Director. The policy did not mention the
Residents Affected - Few The Identification of Abuse section stated that the Abuse Coordinator or his/her designee shall investigate all reports of
investigation. The policy then stated that the abuse coordinator is responsible for reporting to appropriate officials in
accordance with Federal and State Regulations. The policy did not mention the obligation of all staff who witness abuse to
The Investigations section read, The Abuse Coordinator and/or Director of Clinical Services shall take statements from the
officials required by law. This document did not include notification of law enforcement or the abuse coordinator. Also,
this document did not mention sexual abuse.
F 0226 Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of
resident property.
jeopardy Based on observation, resident and staff interviews, and record review, the facility failed to develop and implement
policies to report and investigate sexual abuse of one resident who was cognitively impaired (Resident #1), out of 5
Residents Affected - Few residents reviewed for allegations of abuse or neglect. The facility had knowledge that an employee reported witnessing a
sexual act between Resident #1 and Resident #2 on February 9, 2015, but failed to investigate the allegation of abuse or
report it to the Administrator. In addition, the facility failed to ensure that Resident #1 was protected from the alleged
perpetrator (Resident #2) after the sexual act was observed. Resident #2 continued to reside in the same location within
the facility and to have unencumbered access to Resident #1 and all other residents in the facility from 02/09/2015 through
2/13/2015 at approximately 1:00 pm, when both Residents #1 and #2 were put on one to one supervision. The facility also
failed to identify and act upon sexualized behaviors exhibited by Resident #1 that placed her at risk for abuse. This
resulted in Immediate Jeopardy beginning on 2/09/2015. The facility's failure to prevent and investigate an incident of
sexual abuse, and protect residents from the alleged abuser, placed cognitively impaired residents in the facility at risk
for serious injury, harm, or impairment.
Resident #1 was fully dressed and facing Resident #2. She stated that she followed Employee A to the nurse's station, and
OMB NO. 0938-0391
CORRECTION NUMBER
105917
Level of harm - Immediate observing two residents having oral sex. The UM said that she instructed Employee A to report the incident to the DON. The
jeopardy UM said that when Employee A returned to the floor, Employee A said that the DON told her that both residents were alert
Residents Affected - Few stated that she was not instructed by the DON to do anything more about this incident. When asked, the UM stated that she
depression, and
acts performed on him by female resident. The intervention listed stated, attempt to redirect if found in sex act with
In an interview on 02/12/2015 at 5:08 pm with the DON, she denied saying that nothing could be done about the incident that
occurred between Residents #1 and #2. When asked how she determined that Resident #1 was a consenting adult, she stated
that Employee A and the SSD told her that the resident was sometimes confused, but she was alert and oriented. The DON
added that the resident was able to carry on a conversation, and sometimes converts to Spanish. The DON said that when she
interviewed Employee A, she asked her if both residents were alert and oriented, and Employee A told her they were. She
stated that the SSD then left the room to interview both residents involved, the nurse went back to the floor, and that was
the end of it. The DON stated that she was not aware of any incident between the two residents earlier in the day. She
stated that law enforcement had not been informed of the incident.
The SSD asked the resident about the incident that just happened. Resident #1 stated that there was not a man in her room,
and the incident did not occur.
In an interview on 2/12/2015 at 12:25 pm with the SSD, she stated that she was not told to do any investigation into this
incident. She stated that the DON would be the one to investigate, since she was the Abuse Coordinator. The SSD said she
has had no further involvement in this case.
can be done', so I went back to the floor.
5:52pm.
#2 were not on one to one supervision, and had access to each other. Both came and went from the dining room without
supervision.
OMB NO. 0938-0391
CORRECTION NUMBER
105917
Level of harm - Immediate anything regarding the allegation. The ARNP stated that she sees Resident #1 on a regular basis, and she (the ARNP) doesn't
jeopardy think Resident #1 could consent to having sex. Review of the ARNP's progress note for Resident #1 dated 2/16/15 revealed
Residents Affected - Few and delusions. The ARNP documented that the sexual incident was reported to her on 2/13/15. When the ARNP interviewed
better.
Any employee who witnesses or has knowledge of an act of abuse to a resident is obligated to report such information to the
Clinical Nurse in charge, Director of Clinical Services, and the Executive Director. The policy did not mention the
The Identification of Abuse section stated that the Abuse Coordinator or his/her designee shall investigate all reports of
OMB NO. 0938-0391
CORRECTION NUMBER
105917
Level of harm - Immediate investigation. The policy then stated that the abuse coordinator is responsible for reporting to appropriate officials in
jeopardy accordance with Federal and State Regulations. The policy did not mention the obligation of all staff who witness abuse to
Residents Affected - Few The Investigations section read, The Abuse Coordinator and/or Director of Clinical Services shall take statements from the
officials required by law. This document did not mention sexual abuse, and did not include notification of law enforcement
or the abuse coordinator.
F 0323 Make sure that the nursing home area is free from accident hazards and risks and provides
supervision to prevent avoidable accidents
jeopardy Based on observation, resident and staff interviews, and record review, the facility failed to provide supervision to
prevent abuse for a resident who exhibited sexualized behaviors (Resident #1), out of 5 residents reviewed for abuse or
Residents Affected - Few neglect. The facility had knowledge that Resident #1, who was severely cognitively impaired, exhibited sexualized behaviors
toward Resident #2. The facility did not report these behaviors to Resident #1's psychiatric provider, or protect the
resident from Resident #2, who was at a much higher level of cognitive function. The facility also had knowledge that an
employee reported an allegation of sexual abuse involving Residents #1 and #2 on February 9, 2015, but failed to
investigate the allegation of abuse and ensure that Resident #1 was protected from the alleged perpetrator from 02/09/2015
through 02/13/2015.
After the staff member's allegation, the alleged abuser continued to reside in the same location within the facility and to
have unencumbered access to Resident #1 from 02/09/2015 through 2/13/2015 at approximately 1:00 pm, when both residents
were put on one-to-one supervision. This resulted in Immediate Jeopardy beginning on 2/09/2015. The facility's failure to
to provide supervision of a resident who exhibited sexualized behaviors, and failure to monitor the alleged abuser, placed
cognitively impaired residents in the facility at risk for serious injury, harm, or impairment.
Resident #1 was fully dressed and facing Resident #2. She stated that she followed Employee A to the nurse's station, and
Record review revealed that Resident #1 resided in room #204W. She was [AGE] years old and admitted to the facility on
[DATE], with [DIAGNOSES REDACTED]. The record also showed a [DIAGNOSES REDACTED]. The resident was prescribed
Seroquel 50mg
twice a day for bipolar disorder, Zoloft 50mg daily for depression, and Namenda XR 28mg daily for dementia. The resident's
daughter signed the resident's consents for treatment.
OMB NO. 0938-0391
CORRECTION NUMBER
105917
Level of harm - Immediate information) with a score of 5 (severe impairment) out of a possible 15. She was assessed as not being oriented to year,
jeopardy month, or day, and could recall two out of three items after being cued. She continuously had difficulty focusing her
Residents Affected - Few concentrating on things, such as watching television or reading a newspaper. She had behavior of restlessness or moving
making, makes self understood, and no confusion. Issues assessed at his 1/20/15 neurology appointment included traumatic
brain injury (brain dysfunction caused by a blow to the head) and erectile dysfunction.
The SSD asked the resident about the incident that just happened. resident #1 denied that there was a man in her room, or
that the incident occurred.
#2 were not on one-to-one supervision, and had access to each other. Both came and went from the dining room without
supervision.
better.
OMB NO. 0938-0391
CORRECTION NUMBER
105917
Level of harm - Immediate not put them on one-to-one until after I got back from lunch. She thought it was around 12:30pm. She stated that there were
jeopardy two CNAs assigned to be one-to-one with the two residents now. Regarding re-training for abuse, Employee C stated that she
Residents Affected - Few education on abuse today.

Consulate Health Care of Jacksonville 02-17-2015

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DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED:2/13/2018

CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

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