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Office of Health Facility Complaints: Augustana Nyambane Case

Office of Health Facility Complaints: Augustana Nyambane Case

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Read full Star Tribune coverage here: http://www.startribune.com/investigators/
Read full Star Tribune coverage here: http://www.startribune.com/investigators/

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Published by: stribcarew on Jun 04, 2011
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 Protecting, Maintaining and Improving the Health of Minnesotans
Office of Health Facility Complaints Investigative ReportPUBLICFacility:Augustana HCC of Mpls.1007 East 14th StreetReport # H5242040Minneapolis, MN 55404Hennepin CountyDate: October 23, 2006Date of Visit: 10/25/05By:Deb Vangsness, R.N.Time of Visit: 6:00 a.m.Deborah Neuberger, R.N.Special InvestigatorsNature of Visit:An unannounced visit was made in order to investigate the following allegation of sexual abuse inaccordance with federal regulations for long term care facilities at 42 CFR Part 483, Subpart B. Inconjunction with the federal investigation, an investigation was also conducted in accordance with theVulnerable Adults Act (VAA), Minn.Stat. 626.557.The allegation is: At approximately 4:00 a.m. on 10/21/05, employee (G)/NAR heard resident #1scream in a way that she had not heard before. When she entered the resident’s room, she observedemployee (K)/NAR, the Alleged Perpetrator (AP) at the resident’s bedside. The resident’s blanket hadbeen pulled back, her gown was way up, and he had his fingers in her vagina. Employee (G) screamed.Right then, employee (H)/NAR came in and witnessed the same thing.Investigative Findings:All employees and persons were interviewed in private as desired and given the Tennessen Statement.Resident #1’s medical record was reviewed and indicated that she is completely dependent on staff forall needs, due to multiple health problems. She is unable to communicate (with the exception of a fewutterances), secondary to a stroke, and therefore relies on staff, to anticipate and meet her needs. She isnon-ambulatory and obese, and requires the assistance of two staff for bed mobility. She is checked,changed, and re-positioned by staff every two hours.A Vulnerable Adult report, dated 10/21/05, indicated that employees (G and H)/NARs saw the AP“sexually molesting” resident #1 at 4:20 a.m. Employee (B)/RN notified the police and the AP wastaken into custody. The resident did not have the ability to talk about what happened. She wastransported to the hospital for a sexual assault exam. Employees (G and H) provided written statements.The police secured potential evidence (the resident’s bedding, trash, etc.). The resident’s family wasnotified of the incident.
 General Information: (651) 201-5000 ▪ TDD/TTY: (651) 201-5797 ▪ Minnesota Relay Service: (800) 627-3529 ▪ www.health.state.mn.usFor directions to any of the MDH locations, call (651) 201-5000 ▪ An Equal Opportunity Employer
When interviewed by investigators on 10/25/05, administrative employee (A) confirmed the above andstated: The incident occurred in resident #1’s room on 2 East, during the night shift of 10/21/05, atapproximately 4:20 a.m. The AP was not working on 2 East, during this shift. The AP was assigned toresident care on another floor, Ground East. Employee (A) explained that:
employee (G)/NAR was the assigned nursing assistant on 2 East on 10/21/05.
the AP was the assigned nursing assistant on Ground East on 10/21/05.
employee (H)/NAR was the assigned “float” nursing assistant on 10/21/05 (helps out severalfloors, including Ground East and 2 East, by aiding the assigned nursing assistant with residentcare, such as turning/re-positioning, that requires two people).
employee (D)/RN was the assigned nurse for 2 East and Ground East on 10/21/05.
employee (B)/RN is the day-shift manager for 2 East, who just happened to come in early on10/21/05.
the room where oxygen tanks are re-filled is located on 2 East.Employee (A) also told investigators that when facility staff questioned the AP about why he was inresident #1’s room, he said he went to answer her call light and wash his hands. Employee (A)emphasized that resident #1 doesn’t have the ability to activate the call light and there is no bathroom inresident #1’s room, because the bathroom is under construction. Facility staff had the security guardremain with the AP, until the police arrived. Employee (A) had no credibility concerns regardingemployees (G and H), which was consistent with a review of their personnel files.When interviewed by investigators on 10/25/05, employee (G)/NAR stated: She normally works thenight shift on 2 East. Resident #1 needs “everything” done for her and she usually sleeps throughout thenight. She makes rounds to resident #1’s room, to check her for incontinence and positioning, threetimes during the shift. First rounds are started at 11:00 p.m., second rounds are conducted between 2:00a.m. and 3:00 a.m., and final rounds are started at 4:30 a.m. The “float aide” comes to 2 East and assistsher with the residents that need two people for care. She was working on 2 East during the night shift of10/20 - 10/21/05. She was the only employee on the unit, with the exception of “float” help duringresident rounds (when employee (H)/NAR came to the unit to assist her or when employee (D)/RN cameto the unit for nursing rounds). At approximately 4:30 a.m. on 10/21/05, she was assisting anotherresident back to bed when she heard resident #1 “holler out.” Employee (H) had just arrived on the floorto assist her with rounds. Resident #1 “didn’t sound right…she usually makes noises, but not like this.”Employee (G) went to check on the resident and when she got near the resident’s room, she noticed thewhole room was dark. Usually, the light over the room mate’s bed is left on, because the room mate isafraid of the dark. The room mate’s light was off. Employee (G) was sure she left it on when she did2:00 a.m. rounds. Employee (G) also observed that both of the privacy curtains were closed. Asemployee (G) gingerly stepped into the room, she heard a loud noise and observed the AP laying on topof resident #1 “in a sexual position.” His pants were down to his knees and the resident’s gown waspushed up to just below her breasts. Employee (G) exclaimed, “Oh my God, Oh no!” The AP “jumpedout of bed and pulled his pants up.” He turned his body away from employee (G)’s view, so she wasunable to determine whether or not he had an erection. Employee (H), who had come into the room atsome point, said, “That’s the aide from Ground floor.” Employee (G) indicated the AP appearedsurprised, and he therefore “tried to hide in the room…he would have gone out the window if he couldhave.” Employee (G) instructed employee (H) to remain with the AP, while she notified the supervisorof the situation. Employee (G) then left the room and employee (H) remained with the AP. Employee(G) had seen the AP earlier on the unit, around 4:00 a.m., and employee (G) assumed he was on 2 Eastto refill oxygen tanks. Employee (G) did not see the AP again after that, until 4:30 a.m., when sheobserved him in resident #1’s room. Employee (G) had never worked with the AP on a previousoccasion. Employee (G) thought the AP usually worked second shift. Employee (G) thought it was
General Information: (651) 201-5000 ▪ TDD/TTY: (651) 201-5797 ▪ Minnesota Relay Service: (800) 627-3529 ▪ www.health.state.mn.usFor directions to any of the MDH locations, call (651) 201-5000 ▪ An Equal Opportunity Employer
important for investigators to know that resident #1’s roommate told her that she heard resident #1“hollering ‘Stop, Stop, Stop,’ all week,” prior to the incident of 10/21/05.Employee (G)’s statements to investigators were consistent with information she provided during thefacility’s internal investigation and to the police.Numerous attempts to interview employee (H)/NAR, either in-person or by telephone, wereunsuccessful. However, in a documented statement, prepared by employee (H) during the facility’sinternal investigation, employee (H) indicated that she heard employee (G) scream as she enteredresident #1’s room from the 2 East hallway. The room was dark. Initially, she could see the AP’s “tennisshoes,” underneath the privacy curtain, next to resident #1’s bed. She opened the privacy curtain andobserved the AP, with his hand “inside the resident.” The resident’s legs were spread “wide open,” herincontinent product was off, and he had his hand “inside her.” The AP “tried to run but didn’t knowwhat way to go.” Employee (H) asked the AP, “What are you doing in here?” The AP replied that hewas washing his hands.Employee (H)’s written statement was consistent with what she told the police.Observations revealed that resident #1 resides in a semi-private room on 2 East. There are 38 residentson this unit. Resident #1’s room is located at the end of the unit’s hallway (the farthest room from thenurse’s station). Her bathroom is under construction, due to remodeling. There are no fixtures in thebathroom, the walls are stripped, and the plumbing is visible (photographs taken). The bathroom is notusable (photographs taken).Observations also revealed that the oxygen refill room is located approximately four doors down fromresident #1’s room (photographs taken).Resident #1 was visited. She did not respond to any of this investigator’s attempts to interact with her.Although she was alert, she stared ahead, with a blank expression. She made no eye contact and herlower lip quivered continuously.Resident #1’s roommate was also visited. She was pleasant and conversant, but had no informationregarding the AP or the incident in question. She generally sleeps through the night, and apparently sleptthrough the incident of 10/21/05. Even when prompted, she could not recall that she told staff she heardresident #1 yelling “Stop, stop, stop,” all week long, prior to the witnessed incident of 10/21/05.(According to the two staff who witnessed the incident, the privacy curtain was pulled closed around herbed at the time of the incident, and her night light had been turned off). Her medical record revealed thatshe wears glasses and is legally blind. Her medical record also indicated that she has paranoidschizophrenia. When the police arrived to investigate the incident, on the early morning of 10/21/05, shethought the police came for her and asked staff if she was in trouble.When interviewed by investigators on 10/25/05 at 9:50 a.m., employee (B)/RN stated she arrived towork early on 10/21/05, at 3:45 a.m. (versus her usual start time of 7:00 a.m.), and was sitting at the 2East desk. She noticed the AP go by the desk with some portable oxygen tanks. She went into her officeto do some paperwork and shortly thereafter (4:20 a.m., according to the incident report she prepared),employees (G and H) barged into her office, exclaiming that they “caught the aide from Ground Eastmolesting (resident #1).” Employee (B) immediately checked on resident #1. As she went down the halltoward the resident’s room, she observed the AP “wandering around the corridor (which leads to thenext unit).” The resident was not able to verbalize anything regarding the incident. Employee (B) then
General Information: (651) 201-5000 ▪ TDD/TTY: (651) 201-5797 ▪ Minnesota Relay Service: (800) 627-3529 ▪ www.health.state.mn.usFor directions to any of the MDH locations, call (651) 201-5000 ▪ An Equal Opportunity Employer

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