Palos Verdes Health Care Center
26303 Western Ave Lomita, CA 90717
Citation Number: 910007237
Citation Date: 10/3/2013
Violation Date: 10/30/2009
Class: A
Penalty: $20,000

CLASS A CITATlON - PATIENT CARE

F223
483.13(b) Abuse

The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

The Department received an entity reported incident on November 2, 2009, after a resident (Resident 1) alleged that LVN 1 sexually abused her an three separate occasions while providing care. First kissing her, then grabbing her breast, and most recently touching her private area.

On November 17, 2009, an unannounced visit to the facility to investigate the incident was conducted.

Based on interview and record review, the facility failed to ensure:
1. Resident 1 was free from sexual abuse.
2. Resident 1 felt safe, after the sexual abuse allegation.
3. Resident 1 had no direct contact with the perpetrator after the allegation, and after she expressed she was fearful.

These failures resulted in Resident 1 having a reduction in mental capacity as exhibited by the resident's feeling unsafe, depressed, agitated, and requiring more anti-anxiety medications because LVN 1 continued to work at the facility providing care to her.

Resident 1 was transferred to a general acute care hospital (GACH) for a psychiatric evaluation and stayed for six days due to her agitation. According to the psychiatrist assessment, the resident was fairly stable prior to the incident.

On November 17, 2009, a review of Resident 1's clinical record indicated she was a 55 year-old female admitted to the facility on June 5, 2009, with diagnoses that included hypothyroidism (thyroid gland does not produce a sufficient amount of the thyroid hormones), bipolar disorder (alternating moods of mania with episodes of depression), and insulin dependent diabetes mellitus (requiring insulin to control blood sugar levels).

A review of an annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 2, 2009, indicated the resident's long and short-term memory was intact. The resident's cognitive skill for daily decision-making was moderately impaired (with some difficulty in new situations). The resident had the ability to make herself understood and understand others. The resident required limited assistance (one-person assist) with transferring, personal hygiene, and toilet use, and extensive assistance w~h dressing and bathing.

A review of a Resident Abuse Report Form, dated November 2, 2009, indicated the Incident occurred on October 30, 2009, between the hours of 6-6:30 a.m., on the night shift (11 p.m.-7 a.m.) in Resident 1's room. The report, which was written by the director of nursing (DON), indicated the resident had no behaviors such as sexual misconduct, making similar allegations, and/or any verbal or physical behaviors.

A review of a typed social service Interview with a certified nursing assistant (CNA 1 ), dated October 31, 2009, indicated the social worker called the facility to speak to CNA 1 after Resident 1 informed the facility of the sexual abuse allegation. According to the written interview, CNA 1 stated she heard a call light buzzing and found the resident mad, furious, and crying, indicating LVN 1 touched her private area. CNA 11old the social worker the resident demonstrated to her how LVN 1 touched her. CNA 1 informed the social worker she had called LVN 1 into the resident's room and he walked out of the room mad and upset. The social worker documented she had asked CNA 1 what was LVN 1 's facial expression while in the resident's room, and CNA 1 stated, "He looked guilty and his body language said it more."

According to the director of nursing's (DON) written interview with the resident's family member, dated November 2, 2009, and timed at 9:30a.m., the family member stated the resident has never complained of any sexual abuse before and indicated she thought it would be unusual for the resident to complain of sexual abuse if it had not occurred.

During an interview, on November 17, 2009, at 3:15 p.m., the DON stated the investigation of LVN 1 touching Resident 1 was still in progress, which was 18 days after the allegation. According to the DON, she interviewed the resident on several occasions and the resident related the occurrence of the incident the same each time.

On November 17, 2009, at 3:30p.m., during an interview, Resident 1 stated that in the early morning of October 30, 2009, LVN 1 came into her room to administer her insulin (used to remove excess glucose from the blood, which otherwise would be toxic) and put his hand down her stomach and touched "her crotch" (her private part). The resident stated she yelled out and a certified nursing assistant (CNA 1) came into the room and she told CNA 1 what had occurred. The resident stated CNA 1 brought LVN 1 back into her room and he was very angry and called her a liar in front of CNA 1. Resident 1 stated LVN 1 had kissed and fondled her breast on two other occasions while he was providing care to her. Resident 1 stated CNA 1 told her to call the police the next time LVN 1 did something to her. According to the resident, and as indicated in the social service progress note, dated October 30, 2009, and timed at 8:30 a.m., it was the resident who reported the sexual abuse and not LVN 1 or CNA 1.

A review of a psychiatric evaluation, handwritten by the psychologist, dated November 5, 2009, and timed at 1-2 p.m., indicated he explored the resident's feelings regarding the inappropriate touching by a male employee. The note indicated the resident stated that over the past month (October 2009) LVN 1 had sexually harassed her on three separate occasions. The resident expressed she was quite upset about it. The physician documented the resident informed him that something like sexual abuse had never happened to her before.

A review of a letterhead typed psychiatric re-evaluation, dated November 9, 2009, without a time, indicated the resident was seen secondary to being agitated. Under the Mental Status Exam, the report indicated the resident had no hallucinations, delusions, suicidal or homicidal ideations, and with fair memory and cognitive capacity.

On November 17,2009, at 5 p.m., the administrator stated LVN 1 was not suspended, but should have been until the investigation was completed. The administrator stated, "I have to weigh things, because I have known the LVN since the year 2000."

A review of a social service note, dated November 25, 2009, without a time, indicated the social worker met with Resident 1 and the resident expressed her frustrations about LVN 1 remaining to work at the facility. According to the note, 1he resident had more anxiety and depression after the incident. The social worker encouraged the resident to cry and talk more about her feelings. The social worker documented she informed the resident that the investigation was still ongoing (almost 30 days later).

On December 7, 2009, while at the facility, an unidentified staff member placed a small piece of paper in the surveyor's hand. The note read: Please investigate and do something to that"___" (LVN 1's name) he did it to ______ "(Resident 1's name).

At 9:05 a.m., during an interview, on December 7, 2009, LVN 1 stated he went into Resident 1's room around 6 a.m., on October 30, 2009, to give her insulin. LVN 1 stated after giving the insulin injection to the resident he went back to the nursing station. LVN 1 stated CNA 1 called him into Resident 1's room because the resident had complained that he held her private part. When asked if there were other allegations against him, LVN 1 stated, "I know about two from Resident 1. I heard from another staff that the resident stated I had kissed her before while taking her blood sugar.

On December 10, 2009, at 9 a.m during a telephone interview, CNA 1 stated on October 30, 2009, around 6 a.m., she heard Resident 1 screaming her name. CNA 1 stated she went into Resident 1's room and had to calm her down. CNA 1 stated Resident 1 showed her how LVN 1 grabbed her crotch. CNA 1 stated she went to LVN 1 and brought him to the residents room. CNA 1 stated LVN 1 was irate and told the resident she was a liar and both the resident and LVN 1 were yelling at each other. The resident demonstrated again what LVN 1 had done to her. CNA 1 stated Resident 1 does not lie and had told her of a previous incident of LVN 1 kissing her. CNA 1 stated after the incident on October 30, 2009, LVN 1 would call her to accompany him into Resident 1's, because if he went by himself, the resident would scream. CNA 1 stated Resident 1 would become upset every time LVN 1 was around her and would scream. CNA 1 stated the resident informed her on the morning of the incident she did not tell L VN 1 to giVe her the insulin in her stomach, but wanted it given in her arm.

CNA 1 stated after the incident on October 30, 2009, LVN 1 tried to convince her that Resident 1 was confused and told her, "We have to stick together." CNA 1 stated LVN 1 was very nervous telling her, "I cannot lose my job, I have a sick wife."

A review of a nurse's note dated December 2. 2009, and timed at 7:30 a.m., indicated Resident 1 was exhibiting screaming and yelling outbursts. According to the note, the resident was crying and agitated while refusing care. Another nurse's note, dated the same day, but timed at 4:30 p.m., indicated the resident's family was at the bedside. The resident's physician was called and gave an order to transfer the resident via ambulance to the GACH for a psychological evaluation.

A review of Medication Administration Records (MARs) for October 2009 and November 2009, indicated the resident had a physician's order to receive Klonopin 0.5 mg (used in treatment for anxiety and panic attacks) every four hours whenever necessary (PRN) for anxiety. According to the MARs. the resident received one Klonopin for anxiety in the month of October. However. after the sexual abuse allegation in October 2009, the resident received eight Klonopin (0.5 mg) in the month of November 2009.

A review of the GACH's Emergency Room nurse's note, dated December 2, 2009, and timed at 5:09 p.m., indicated the resident was transferred to the hospital after being assaulted by a staff member three times and being angry that he was still working in the facility. The nurse's note indicated the resident stated, "I reported the assault to the facility, but nothing was done and I'm angry he still works there." The note further indicated the Sheriffs Department was called and a deputy arrived and took a report.

A review of an electronic "Admission Psychiatric Evaluation" dictated on December 3, 2009, at 12:09 p.m., indicated under history of present illness, the resident who had been fairly stable until a few weeks ago (incident occurred a few weeks prior), has become increasingly labile (unstable/fluctuating mood) and agitated. The physician dictated there were reports that the resident had reported being touched in her private area by one of the staff. Reportedly, the physician dictated the resident had become agitated and fearful. The psychiatrist dictated under Weaknesses and Strengths, the resident's strengths included her history of cooperation with treatment.

Resident 1 received psychiatric treatment for six days with medication changes while in the GACH and was discharged on December 8, 2009.

A review of a "Victim Notification Hearing" dated, July 23, 2010, and timed at 8 a.m., indicated Resident 1 was scheduled to appear in the case against LVN 1 after he was charged with a crime (unprofessional conduct- excessive force, mistreatment or abuse).

The facility failed to ensure:

1. Resident 1 was free from sexual abuse.
2. Resident 1 felt safe, after the sexual abuse allegation.
3. Resident 1 had no direct contact with the perpetrator after the allegation, and after she expressed she was fearful.

The above violations jointly, separately, or in any combination presented a substantial probability that death or serious physical or mental harm would result.