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Office of Health Facility Complaints: Westwood

Office of Health Facility Complaints: Westwood

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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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06/04/2011

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Protecting,MaintainingandImprovingtheHealthofMinnesotans
OfficeofHealthFacilityComplaintsInvestigativeReportPUBLICFacility:WestwoodHealthCareCenter7500West22ndStreetS1.LouisPark,Minnesota55426HennepinCountyReport
#:
H5182043Date:November20,2008DateofVisit:March18,2008TimeofVisit:1:45p.m.By:MichelleNess,R.N.SpecialInvestigatorNatureofVisit:Anunannouncedvisitwasmadeinordertoinvestigatethefollowingallegationofsexualabuseinaccordancewithfederalregulationsforlongtermcarefacilitiesat42CFRPart483,Subpart
B.
Inconjunctionwiththefederalinvestigation,aninvestigationwasalsoconductedinaccordancewiththeVulnerableAdultsAct(VAA),MinnesotaStatutes§626.557andstatenursinghomelicensurerules,Chapter4658.Theallegationis:Resident
#1
resided
in
thefacilityfromJune15,2007untilSeptember10,2007.Duringherresidence,shewassexuallyassaultedbyemployee(A)/alJegedperpetrator(AP)ontwooccasions.Onthefirstoccasion,afterthe
AP
assistedherinthebathroom,andwhentheresidentwaswipingherself,theAPstuckhisfingersintotheresident'svaginaandbeganrubbing.ThesecondincidentoccurredwhentheAPlifteduptheedgeoftheresident'snightgown,puthishandsonherunderpantsandstartedtotakethemoff.The
AP
stoppedwhentheresidentslappedhishandawayandsaid"no."InvestigativeFindings:AllemployeesandpersonswereinterviewedinprivateasdesiredandgiventheTennessenStatement.Duringthecourseoftheinvestigation,thefollowingtaskswerecompleted:Resident#l'smedicalrecordwasreviewed.TheAP'spersonnelfilewasreviewed.Incident/accidentreportsbetweenFebruary2008andJuly2008werereviewed.PoliciesandproceduresrelatedtotheVulnerableAdultsActandgeneralorientationwerereviewed.Thefacility'sinternalinvestigationrelatedtotheallegationwasreviewed.Multipleattemptstoobtainthepolicereportviafaxedrequestandtelephonecallstothepolicedepartmentandthecountyattorney'sofficewereunsuccessful.
GeneralInformation:(651)201-5000TDD!TTY:(651)201-5797MinnesotaRelayService:(800)627-3529www.health.state.mn.usFordirectionstoanyoftheMDHlocations,call(651)201-5000
An
EqualOpportunityEmployer
 
WestwoodHealthCarecenterH5182043Page2of2StaffingfortheweekofMarch17,2008wasreviewed.Conclusion:
Sexualabuseisinconclusive.
Conflictinginformationfromtheprinciplepeopleinvolvedwasobtained,andnoevidencewasidentifiedthatgavemorecredencetooneovertheother.Documentationandinterviewrevealedthefollowing:Resident#1wasadmittedtothefacilityforrehabilitationduetoaprostheticinfection.Theresidentwasidentifiedasalertandorientedbutrequiredassistancefromstafffortoiletingandtransferring.Resident#Iwheninterviewed,statedthatsherequiredstaffforstandbyassistanceasneededwheninthebathroom.Ononeoccasion,thespecificdateunknown,theAPassistedtheresidentinthebathroom.Oncetheresidentfinishedusingthebathroom,shestoodupandtheAP,whowasstandingbehindher,reachedbetweenherlegswithhishandandwiggledhisfingersonher"privateparts."TheresidentstatedthattheAPdidhaveglovesonbutdidnothaveanytoiletpaper.SometimeafterthatwhentheAPwasassistingtheresidentintobed,hestuckhishandinthewaistbandofherunderpants.TheresidentsaidthatsheslappedtheAP'shandandthenhetookhishandoutofherpants.Resident#1deniedsayinganythingtotheAPoneitheroccasion.However,shedidreporttheincidentstoemployee(E).TheAP,wheninterviewed,deniedtheallegations.Althoughhedidrecallassistingresident#1inaccordancewithhercareplan,hecouldnotrecallanyincidentinwhichhestuckhishandsbetweentheresident'slegsotherthantowipetheresidentaftertoileting.
In
addition,hecouldnotrecallanyincidentinwhichhestuckhisfingersinsidethewaistoftheresident'sunderpants.Asaresultoftheinvestigationthefacilitydidreceiveonefederaldeficiency,tagF225,andonestatelicensingorder,MNStatute626.557,Subd.4a,relatedtothefacility'sfailuretoensurethatstaffinternallyreportallegationsofsexualabuse.Arevisitwasconductedandthedeficiencyandlicensingorderwerefoundto
be
correctedonMay6,2008.xc:DivisionofComplianceMonitoring-Licensing
&
Certification
 
DEPARTMENTOFHEALTHANDHUMANSERVICESCENTERSFORMEDICARE
&
MEDICAIDSERVICES
STATEMENTOFDEFICIENCIESANDPLANOFCORRECTION(X1)PROVIDER/SUPPLIER/CLIAIDENTIFICATIONNUMBER
245182PRINTED:
04/01/2008
FORMAPPROVED
OMSNO0938-0391
(X2)MULTIPLECONSTRUCTION
A
BUILDING
C
03/2012008
NAMEOFPROVIDERORSUPPLIER(X3)DATESURVEYCOMPLETEDB.WING_PROVIDER'SPLANOFCORRECTION(EACHCORRECTIVEACTIONSHOULDBECROSS-REFERENCEDTOTHEAPPROPRIATEDEFICIENCY)
WESTWOODHEALTHCARECENTER
LABORAJ9RYDIRECTOR'SO~PRO~E~PPLIERREPRESENTATIVE'SSIGNATURE
r
I
fIE
(X6)
DATE
:
7771
~~AhA-~
4-
9-(J!
(X4)10
I
PREFIXTAG;SUMMARYSTATEMENTOFDEFICIENCIES(EACHDEFICIENCYMUSTBEPRECEDEDBYFULLREGULATORYORLSCIDENflFYINGINFORMATION)STREETADDRESS,CITY,STATE.ZIPCODE
7500WEST22NDSTREET
SAINTLOUISPARK,MN55426
IDPREFIXTAG
F000
WestwoodHealth
Care
Centerobjectstoanddisagreeswithboththefindingsofnon-complianceandthelevelofdeficiencycited.
IX5)
COMPLETION
DATE
2/11/08
F000)INITIALCOMMENTS,Anabreviatedstatndardsurveywasconductedto
!
investigatecase#H5182043.Asaresultthefollowingdeficiencyisissued.F225483.13(c)(1)(ii)-(iii),(c)(2)(4)STAFF5S=0TREATMENTOFRESIDENTS
I
Thefacilitymustnotemployindividualswhohave:beenfoundguiltyofabusing,neglecting,ormistreatingresidentsbyacourtoflaw;orhavehadafindingenteredintotheStatenurseaideregistryconcemingabuse,neglect,mistreatmentofresidentsormisappropriationoftheirproperty;andreportanyknowledgeithasofactionsbyacourtoflawagainstanemployee,whichwouldindicateunfitnessforserviceasanurseaideorotherfacilitystafftotheStatenurseaideregistryorlicensingauthorities.
SubmissionoftheCredibleAllegationsofCompliance
isnota
legaladmissionthat
a
deficiency
exists
or
thatthe
StatementsofDeficiency
were
correctlycited.Itisalsonotto
be
construedasanadmissionagainsttheinterestsoftheFacility,itsAdministratororanyemployees,agentsorotherindividualswho
draft
ormay
be
discussedinthisCredibleAllegationofCompliance,
Thefacilitymustensurethatallallegedviolations,involvingmistreatment,neglect,orabuse.includinginjuriesofunknownsourceandmisappropriationofresidentpropertyarereportedimmediatelytotheadministratorofthefacilityandtootherofficialsinaccordancewithStatelawthroughestablishedprocedures(includingtotheStatesurveyandcertificationagency).Thefacilitymusthaveevidencethatallallegedviolationsarethoroughlyinvestigated,andmustpreventfurtherpotentialabusewhiletheinvestigationisinprogress.Theresultsofallinvestigationsmustbereported-,totheadministratororhisdesignatedrepresentativeandtootherofficialsinaccordancewithStatelaw(includingtotheStatesurveyandcertificationagency)within5workingdaysoftheincident,andiftheallegedviolationisverifiedF225
Accordingly,
we
aresubmittingthisCredibleAllegationofCompliancesolelybecausestateandfederallawmandatesubmissionofaCredibleAllegationofCompliance
within
ten(10)daysofreceiptoftheStatementofDeficienciesas
a
condition
to
participate
in
the
Medicare
andMedicalAssistanceprograms.ThesubmissionoftheCredibleAllegationofCompliance
within
thistimeframeshould
in
no
waybe
consideredorconstruedasagreement
with
theallegationsofnon-complianceoradmissions
by
thefacility.Whentheadministratorbecameawareof
the
residentcompJainton
February
11,
2008,
the.
a1legat
perpetraSor
was...
r..,'."/.,.
suspendedfro,,"~ofk~the
f<Pfttr..'.(",\
init,\at.e4
C(
8J
n~'inVeStigatiolr~::1)
,.1'1
~'.~~i;
!.;
i;
I
:J
R.
11
('C
r':Q'
I__):
J
\.\1
{\I
I
L
V~CI
L_
AnYdeficrencystatementendinqWithanasterisk(*)denotesadeficiencywhichtheinstitutionmaybeexcusedfromcorrectingprovid'ng
it
isdeterminedthatothersafeguardsprovidesufficientprotectiontothepatients.(Seeinstructions.)Exceptfornursinghomes,thefindingsstatedabovearedisclosable90daysfollowingthedateofsurveywhetherorno!aplanofcorrectionisprovided.Fornursinghomes,theabovefindingsandplansofcorrectionaredisclosable14daysfollowingthedatethesedocumentsaremadeavailabletothefacility.Ifdeficienciesarecited,anapprovedplanofcorrectionisrequisitetocontinuedprogramparticlpation.
FORMCM2567(099)PreviousVersionsObsoleteEvent1061ZLt1
.----
..
-~~
i.':
.<'._,""'"
V.,l..~'.'.'",-,.'
Facility10
00278
IfcontinuationsheetPage1of3

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