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Office of Health Facility Complaints: Westwood Juma Case

Office of Health Facility Complaints: Westwood Juma Case

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02/13/2013

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Protecting,MaintainingandImprovingtheHealthofMinnesotans
OfficeofHealthFacilityComplaintsInvestigativeReportPUBLICFacility:WestwoodHealthCareCenter7500West22ndStreetSLLouisPark,MN55426HennepinCountyReport#:H5182047Date:June8,2009DateofVisit:
02(19/09
TimeofVisit:8:30a.m.By:DeboraVangsness,R.N.ChristineBodick-Nord,R.N.SpecialInvestigatorsNatureofVisit:Anunannouncedvisitwasmadeinordertoinvestigatethefollowingallegationofsexualabuseinaccordancewithfederalregulationsforlongtermcarefacilitiesat42CFRPart483,SubpartB.Inconjunctionwiththefederalinvestigation,aninvestigationwasalsoconductedinaccordancewiththeVulnerableAdultsAct(VAA),MinnesotaStatutes§626.557andstatenursinghomelicensingrules,Chapter4658.Theallegationis:Resident#1wassexuallyabusedbyastaffperson.Afterbreakfastonthemorningof
02/10/09,
employee(G)/nursingassistant,theAllegedPerpetrator(AP),wentinandoutofresident#1'sroom,althoughhewasnotworkingonthatstation.Oneofthetimeshewentin,hekissedher.Shesaid"no"andheleft,butthenreturnedandbegankissingheragain.Shetoldhim"no"andthenshegotupbecauseshehadtogotothebathroom.Hershortswerelooseandfelldownwhenshestoodup.TheAPthenpulledouthispenisandputhisfingersinhervagina.Whenemployee(F)/NAknockedonthedoor,theAPputhispenisawayandwalkedoutoftheroom.InvestigativeFindings:AllemployeesandpersonswereinterviewedinprivateasdesiredandgiventheTennessenStatement.Duringthecourseoftheinvestigation,thefollowingwasreviewed:Resident#l'smedicalrecord.Thefacility'sstaffingpatternandhousestaffingfor
02J
1
OJ09.
Thefacility'sinternalinvestigation.Thefacility'svideosurveillanceofStation4(whereresident#1resides)onthemorningof
02/10(09.
ThepersonnelfilesoftheAPandemployee(F).Inadditiontotheabovereview,theinvestigator:ObservedresidentcareandstaffinteractionwithresidentsonStation4andStation
1,
GeneralInformation:(651)201-5000·TDD/TTY:
(651)
201-5797MinnesotaRelayService'.(800}627-:)52www.health.state.mn.usFordirectionstoanyoftheMDHlocations,call(651)201-5000·AnEqualOpportunityEmployer
 
WestwoodHealthCareCenterH5182047Page2of7Observedtheareawheretheallegedincidentoccurred.Interviewedstaff.ConferredwiththePoliceDepartment.
MedicalRecord:
Resident#1hasresidedinthefacilityforoverthreeyears.Resident#1suffersfrommorbidobesity.Asaresult,hercareplanindicatesthatsherequiresstaffassistancewithmanyactivitiesofdailyliving.Shecannotmoveherselfindependentlywhensheisinbed,norcansheliftherlegsontothebed.Sherequiresextensiveassistanceforambulation,butisindependentwithwheelchairmobility.Sheutilizesabedsidecommodeandcanindependentlygetonandoffthecommode,butneedsstaffassistancewithperinealcare.Sheisalert,oriented,andcanintelligentlyexpressherneeds.Theminimentalstatusexamination,conductedon
09/18/08,
ratedherashavingnormalcognitivefunctioning.Resident#l'scareplanalsonotedthatshehadpoorself-esteem,ahistoryofself-injuriousbehavior(cuttingherself},andapriorhistoryofsuicidalthreatsandattempts.TheBurnsDepressioninventory,conductedon
09/18/08,
ratedherashavingseveredepression.Theprogressnoteson
02/09
and
02/10/09
reflectedthatresident#1hadcomplaintsof"feelingsick."Shewasnauseated,haddiarrhea,refusedmeals,andspentmostofbothdaysinbed.Theprogressnotes,dated
02111/09,
reflectedthatthepolicehadbeennotifiedandaninvestigationwasstartedregardingthe"resident'sallegations."Documentationon
02/11109
indicatedthataSANEnurse(sexualassaultnurseevaluator)examinedtheresident.Thesexualassaultexamindicatedthattheresidentwasexaminedat2:30p.m.on
02111/09,
andthattheincidentofsexualassaulthadoccurredon
02/10109
between8:30a.m.and10:30a.m.TheresidenttoldtheSANEnursethattheAPenteredherroomonthreeseparateoccasionsduringthemorningof
02/10J09
andapproachedhersexuallyoneachoccasion.TheAPkissedheronhermouthtwotimes,touchedherclitoris,anddigitallypenetratedher.Theresidentalsosaidthatshedidn'tknowiftheAPejaculatedbecausehewasunabletoattainafullerection.TheSANEnursenotednophysicalinjuriesuponexaminationofher,butdidnotethattheresidentcomplainedofdiscomfortduringurination.TheresidentalsoexpressedfearoftheAP.ForensicspecimenswerecollectedandsenttotheBCA(BureauofCriminalApprehension).Theprogressnotes,dated
02/12/09,
indicatedthatemployee(B)/LSWmetwiththeresidenttodiscusstheallegedincidentof
02110/09
andanycounselingfollow-upthatwasneeded.Theresidentdeclinedcounseling.SheexpressedconcernregardingtheAP'swhereaboutsandwasworriedthathemightstillbeworkinginthebuilding.Employee(B)reassuredtheresidentthattheAPhadbeenremovedfromduty.On
02/13/09,
resident#1contactedemployee(S)/LSWandindicatedshewantedanappointmentwiththerapist(K).TheresidentcommentedaboutmovingoutofthefacilityduetoherfearoftheAP,whomshe"seeswhenshecloseshereyes."On
02/16109,
resident#1hadacounselingsessionwiththerapist(L)whonotedthatshehadaccusedoneofthestaffof"molestingher"on
02/10109.
Theprogressnoteindicatedthatthematterwasunderinvestigationandthattherewas"atleastsomecircumstantialevidencethatherreportmaybetrue."Theprogressnotealsoreflectedthattheresidentwasexperiencingsomesymptomsofacutestressdisorder(ie.,seeingtheperpetratorwhensheclosedhereyes,moreanxiety,etc.)On
02/18109,
resident#1hadacounselingsessionwiththerapist(K)and"processedfeelingsaroundincidentof02/1
0/09."
 
WestwoodHealthCareCenterH5182047Page
3
of7
InternalInvestigation:
Onthemorningof
02/11/09,
resident#1toldherprimarycaregiver,nursingassistant(J),thattheAPhadsexuallyassaultedherthepreviousmorningof
02110109.
On
02/10109,
nursingassistant
(1)
hadthedayoffsonursingassistant
(F)
wasassignedtoresident#1'scareandtheresidentwasnotcomfortablereportinganincidentofsuchapersonalnaturetonursingassistant(F).Documentationnotedthatresident#1reportedthemattertonursingassistant(J)at7:30a.m.on
02111109,
duringmorningcare,whenshestartedcryingandstatedshewasgladtoseehim.Nursingassistant
(1)
immediatelyreportedtheresident'sallegationtonurse
(D)/LPN,
whocontactedsocialworker
(B).
Aninternalinvestigationensued.TheAP'semploymentwassuspended.ThematterwasreportedtothepoliceandOHFC.ThefacilitymadearrangementsforaSANEnursetoexaminetheresidenton
02/11109.
Inadditiontointerviewingresident#1,thefacilityalsointerviewedotheremployeeswhowereondutyon
02/10/09.
Thefacilityreviewedtheunit'svideosurveillancetapesfrom
02110109.
Thefacilityhadnotinterviewedthe
AP,
pertheadviceofpoliceofficer(I).Thefacility'sinvestigationwasongoing,
at
thetimeofthe
OHFC
investigation.
Observations:
Station1islocatedonthefacility'sfirstfloor(wheretheAPisassignedtowork).Station
4
islocatedonthefacility'ssecondfloor(whereresident
#1
resides).Station
4
isequippedwithvideosurveillance,whichcapturesactivityinthehallwayonly.Residentroomsarenotequippedwithvideosurveillance.Thevideocamera,whichcapturesactivityinresident#1'shallway,islocatednearthenurse'sstation.Thenurse'sstationisapproximately32feetfromresident#1'sroom.Thevideosurveillancetapefrom
02/10/09
revealed:oTheAPenteredresident#1'sroomat8:43a.m.Hestayedintheroomfor5minutes.aTheAPre-enteredresident#1'sroomat8:48a.m.Hestayedintheroomfor15seconds.
o
TheAPre-enteredresident#1
's
roomat9:47a.m.Hestayedintheroomfor
2
minutes.
o
TheAPre-enteredresident#1'sroomat10:13a.m.Hestayedintheroomfor8minutes.Nursingassistant
(1)
wasobservedinthehallat10:19a.m.
o
TheAPcameto2
nd
floorat10:46a.m.Duetoequipment/cartsinthehallway,thevideodoesnotcapturewherethe
AP
goes.However,thevideodoesdemonstratethattheAPcomesoutofresident#1'sroomat10:52a.m.,andthenleavesthefloor.
Interviews:
Interviewwithresident#
1
on
02119/09
Shehasresidedonstation
4(2
nd
floor)foralongtime.Sheformerlyresidedonstation
I
(1
st
floor),wheretheAPworks,butshedidnotknowtheAPwhenshelivedonstation1.SheknowstheAPonlyfromseeinghimintheelevatororseeinghimwhenheisassistingotherresidentsbackto
2
nd
floor,fromthe
lSI
floordiningroom.Sheidentifiedthe
AP
byfirstnameandphysicaldescription.On
02/10109,
atapproximately8:30a.m.,the
AP
enteredherroom.
o
Shewassittinginherlift-reclineratthetime.
o
TheAPwalkedovertowardherandstartedkissingheronthemouth.oShetoldhimto,"Stop...you'llgetintotrouble."TheAPthenleft.Approximately15minuteslater,theAPcamebacktoherroom.

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