P. 1
Office of Health Facility Complaints: Albert Lea

Office of Health Facility Complaints: Albert Lea

|Views: 70|Likes:
Published by stribcarew
Read full Star Tribune coverage here: http://www.startribune.com/investigators/
Read full Star Tribune coverage here: http://www.startribune.com/investigators/

More info:

Published by: stribcarew on Jun 04, 2011
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

02/13/2013

pdf

text

original

Protecting, Maintaining and Improving the Health of Minnesotans

Office of Health Facility Complaints Investigative Report PUBLIC Facility: Good Sam Society Albert Lea 75507 240th Street Albert Lea, MN 56007 Freeborn County Date of Visit: 517/2008 Time of Visit: 9:30 a.m,

Report #: H5441 019 Date: 8/5/2008

By:

Jolene Bertelsen, R.N. Special Investigator

Nature of Visit: An unannounced visit was made in order to investigate the following allegation of abuse in accordance with federal regulations for long term care facilities at 42 CFR Part 483, Subpart B. In conjunction with the federal investigation, an investigation was also conducted in accordance with the Vulnerable Adults Act (VAA), Minnesota Statutes, §626.557 and state nursing home licensing rules, Chapter 4658. The allegation is: Fifteen residents of the facility (residents 1-15) are being physically and mentally abused by five nursing assistants (Alleged Perpetrators 1-5). Investigative Findings: All employees and persons were interviewed in private as desired and given the Tennessen Statement. The investigation included a review of the following: Resident #1-15's medical records; the facility's internal investigation; staff schedules and assignments for April and May of 2008; Incident and Accident reports for February, March, and April of 2008; the APs personnel files, including orientation and training; and policies and procedures in regard to the Vulnerable Adults Act, and the facility's abuse prevention plan. A tour of the units where residents #1-15 resided and observations of interactions between staff and residents was conducted. Several staff and many residents were interviewed during the course of the investigation. Interviews of the APs with the Albert Lea Police Department were videotaped and observed by the OHFC investigator. Transcripts of the interviews were also obtained. Although alleged perpetrator #5 was named in the allegation as an alleged perpetrator, the investigation did not find any substantiated findings related to her in regard to abuse or neglect.

Internal Investigation:
On 51112008, AP #5 was terminated for unrelated circumstances, and was at the facility on 5/2/2008 for an exit interview. During the course of the interview, AP #5 reported allegations of abuse by AP #1 to two residents. AP #1 was placed on suspension, pending an internal investigation. On 5/3/2008, employee (K) came forward, and indicated that she had witnessed abuse by AP #1, 2, 3, and 4. AP # 2,
General Information: (65\) 201-5000' TDDfTfY·. (651) 201-5797· Minnesota Relay Service: (800) 627-3529' www.nealth.stare.mn.us For directions to any of the MDH locations, call (65\) 20 \-5000' An Equal Opportunity Employer

Good Sam Society Albert Lea

H5441019

Page 2 of 14

#3, and #4 were placed on suspension the following morning. The police department and the Common Entry Point were notified on 5/1/2008, and again 5/412008-5/8/2008. On 5/4/2008, employees (G), (H), (I), and (I)/administrative staff brought in a team of facility nurses to do head to toe assessments of al1 of the residents on station one and station four, interviewed all of the interviewable residents to see if they are provided good care, and to see if they have any concerns. AU staff were interviewed and asked about any concerns, and reminded that they are mandated reporters. A mandatory training was implemented for all employees on the Facility Procedures for Reporting Maltreatment of Vulnerable Adults and Your Responsibility as a Mandated Reporter. Administrative staff conducted interviews, and were present during the interviews by the Albert Lea Police Department.

Medical Records:
The investigation revealed that three of the residents named in the allegation are deceased. The remaining residents were visited during an on-site investigation, and their medical records were reviewed. The visits and medical record reviews revealed the following: Resident #1 is deceased. He had diagnoses including Alzheimer's dementia. He required the assistance of two staff with all of his activities of daily living. His care plan states that he was easily annoyed, made repetitive statements, and had episodes of yelling out. Resident #2 has diagnoses including Alzheimer's disease, and dementia with delirium. She requires assistance from staff for all of her activities of daily living. Her care plan states that she has verbal expressions of sadness over the death of her husband, and feelings of worthlessness and helplessness. She was visited on 517/2008 and 5114/2008, but was sleeping with each visit to her room. Resident #3 has diagnoses including dementia with psychosis. She requires the assistance of staff for all of her activities of daily living. Her care plan states that she is verbally abusive to staff, and makes sexually inappropriate comments to staff. She was visited on 517/2008, but was unable to be interviewed due to her cognitive impairment, Resident #4 has diagnoses including Alzheimer's dementia with behavioral disturbances and psychosis. She is also legally blind. Her care plan also indicates that she can be resistive with cares, and will strike out at staff. She was visited on 5/7/2008, but was unable to be interviewed due to her cognitive impairment. Resident #5 has diagnoses including dementia with agitation. His care plan indicates that he requires the assistance of one or two for aU of his activities of daily living. It also indicates that he can be "grabby," and combative with cares. He was visited on 5/14/2008, but was unable to be interviewed due to his cognitive impairment. Resident #6 has diagnoses including dementia, and Alzeimer's disease. Her care plan indicates that she requires the assistance of one for all of her activities of daily living. Her care plan also indicates that she is easily annoyed, and talks to people in her room that are not there. She was visited on 5114/2008, but was unable to be interviewed due to her cognitive impairment.

Good Sam Society Albert Lea

H5441019

Page 3 of 14

Resident #7 has diagnoses including Alzheimer's disease and dementia. She also has macular degeneration, and is legally blind. She was visited on 51712008, but was sleeping with each visit to her room. Her care plan indicates that she requires assistance of one or two for all of her activities of daily living, depending on her level of cooperation each day. Her care plan also indicates that she has poor memory recall, and poor decision making ability. Resident #8 is deceased. Her diagnoses list included dementia, episodic mood disorder, and organic brain damage. Her care plan indicates that she required total assistance from staff with all of her activities of daily living, and transfers. Her care plan also indicates that she had a history of psychosis and was agitated easily. Resident #9 has diagnoses including dementia. Her care plan indicates that she requires total assistance with all of her activities of daily living. Her care plan also indicates that she can be physically and verbally aggressive with staff. She was visited on 517/2008, but due to her cognitive impairment, was unable to be interviewed. Resident # 10 has diagnoses including dementia with delirium. Her care plan indicates that she has alterations in her mood and behaviors, and has episodes of restlessness, agitation, and paranoia. She requires total assistance with all of her activities of daily living. She was visited on 5114/2008, but due to her cognitive impairment was unable to be interviewed. Resident #11 has diagnoses including dementia and Alzheimer's disease. His care plan indicates that he is independent with mobility, and participates with his activities of daily living. He has poor memory recall, and impaired decision making abilities. He was visited on 5/7/2008, but due to his cognitive irnpairment, was unable to be interviewed. Resident #12 has diagnoses including dementia and Alzheimer's disease with behavioral disturbances, and macular degeneration. She requires the assistance of two staff for all of her activities of daily living. Her care plan indicates that she has episodes of anger toward staff, and is easily annoyed. She will yell and hit out with cares, and is difficult to redirect. She was visited on 5/14/2008, but was unable to be interviewed due to her cognitive impairment, Resident #13 has diagnoses including Alzheimer's disease. She requires total assistance with her activities of daily living. She will assist with cares with verbal cues. She has short-term and long-term memory loss, and requires frequent cues in her decision making. She was visited on 5/14/2008, but due to her cognitive impairment, was unable to be interviewed. Resident # 14 has diagnoses including progressive dementia, transient cerebral ischemia, and Parkinson's disease. Her care plan indicates that she requires the assistance of one or two with transfers. She has short-term and long-term memory loss, and impaired decision making abilities. She was visited on 5/14/2008, but was unable to be interviewed due to her cognitive impairment. Resident #15 fracture. Her living. It also craw] into bed is deceased. She had diagnoses including dementia, and a traumatic tibia and fibula care plan indicates she required the assistance of one with all of her activities of daily indicates that she is sexual toward staff, and will grab at their breasts, and want staff to with her.

Good Sam Society Albert Lea

H5441019

Page 4 of 14

Interviews: AP #5/nursing assistant (NA) was interviewed on 5/14/2008 at 5:00 p.m. and stated the following: • On 51112008, she went to the facility for an exit interview, following her termination for swearing in front of a resident. The Director of Nursing began to talk to her about how swearing is verbal abuse to the resident's. She talked about how the residents feel, and AP #5 felt that she had to tell her about AP #1. She stated that AP #1 would poke the resident's breasts, and tap them on the forehead. She would stick her fingers in their mouths, and hit the guys in the "downstairs" area (indicating the peri area) to make them scream, because she thought it was funny. • AP #5 stated that she witnessed a "couple of times," AP #1 hit resident #1 in the peri area. She poked and hit resident #2 in the breasts, put her fingers in her mouth, and hit her in the forehead. Resident #2 would "scream help and just scream." She stated that the above incidents would happen during cares, and she would do it while "I worked there ... 1 know she did it quite a bit." • She indicated that she would do it to other residents also, but she couldn't remember the names of these residents. • She stated that AP #1 did it to residents who "couldn't do anything about it." Most of these residents couldn't speak for themselves. • She denied participating in any abusive behavior to any of the residents. She stated that AP #1 was the only employee that she witnessed doing these things to the residents. • She stated that she was in "shock," She knew she should have reported it, but she was "scared." She stated that they were "taught to tell right away, but 1 never really expected myself to be in that situation, to be witnessing it." AP #5 was interviewed and video taped at the Albert Lea Police Department on 5/6/2008 at 6:30 p.m. and her interview with the Office of Health Facility Complaints investigator was consistent with the interview conducted by the police department. She also stated in the police interview that AP #1 would poke residents in the breasts, and hit the male residents' in the genital area. She would put on gloves and stick her fingers in the residents' mouths, or up their noses to make them scream. She witnessed AP #1 poke resident #2 in the breasts, and put her fingers into her mouth until resident #2 screamed. She stated that this occurred a while ago, in the winter. AP #5 witnessed AP #1 "tap" resident #1 in the genitals, so that he would scream. She stated that the tap was enough to "hurt any guy, hard enough to make a man cry." She stated that this occurred prior to resident #1 dying, approximately two months earlier. She stated that AP #1 "thought that it was funny." AP #5 stated that AP #1 told her that AP #2 would get into bed with the resident's and "hump them." She stated that she should have reported this earlier, but she was scared. Employee (T)!nurse was interviewed on 5/15/2008 at 8:15 a.m. and stated the following: • On 3/2112008, while away from the facility, AP #5 told her that there were "things going on there" (indicating the nursing home) that she was uncomfortable with. She didn't go into any details, of whom or what was speaking, just that she was "uncomfortable, with certain things." "Right away I told her, you need to report something, if you think it's bad or whatever is going on." She indicated that she never checked back with AP #5 to see if she reported anything. Employee (T) was interviewed and video taped at the Albert Lea Police Department on 5(5/2008 at 11:05 a.m., and her interview with the Office of Health Facility Complaints investigator was consistent with her interview conducted by the police department. AP #1 was interviewed on 5/15/2008 at 3:35 p.m. and stated the following:

Good Sam Society Albert Lea

H544 1019

Page 5 of 14

• •

On 51212008, she was placed on suspension in regard to a complaint of abuse at the facility. She stated that she and AP #5 had a confrontation at the facility. AP #1 stated that AP #5 "thinks that she got her fired," and that is why all of these allegations came out. She indicated that she worked with AP #5 only on one occasion. She denied being verbally, physically, or emotionally abusive to any resident. Each resident named in the allegations was mentioned, and she was asked if there was anything she had heard of, or had participated in. She denied any involvement or any inappropriate behavior with each resident listed. She did admit to the detectives at the Albert Lea Police Department that she "spit in resident #3's mouth," but during the interview with the Office of Health Facility Complaints Investigator, stated "I had told them I didn't do it, and they (the detectives) didn't believe me." She admitted to the detectives that she and AP #2 poked resident #9 in the "boobs" but denied the incident during this interview. She has had training in caring for residents with dementia.

AP#l was interviewed and video taped at the Albert Lea Police Department on 51612008 at 4:35 p.m. She also admitted to spitting in resident #3's mouth, and stated that it was "due to immaturity." She stated that she and employee (M) were putting resident #3 to bed, and she was reaching over resident #3 to get something, and she spit in resident #3'5 mouth. She also admitted that she and AP #2, on more than one occasion, poked resident #9 in the "boobs," She stated AP #2 covered a resident's mouth to keep them from crying out. AP #2 told her about "filling her mouth with water, and spitting it" on resident #12. She admitted to "pinching" resident #7's nipple, only one time. She stated that AP #2 was in the room also. She witnessed that AP #2 "rubbed hard" on resident #2's peri-area, and she laughed about it. AP #4!NA was interviewed on 5128/2008 at 3:10 p.m, and stated the following: • All of the residents named in the allegations were listed, and she was asked if she was aware of any incidents' related to each specific resident. She stated that she heard that AP #1 spit in resident #3's mouth. She stated she couldn't remember where it was, but "we were all talking and it was said." • She stated that she heard there was an incident with resident #5. He would always get mad when someone took his hat off. She stated that he «freaked out, and starts swearing" and they thought it was funny, so AP #2 took a video of him getting mad. She did see the video. • She stated that resident #15 was a very touchy lady, and when asked about poking her in the breasts, she stated, "If she was joking around, and we were joking around, I wouldn't purposely go up to her and poke her in the boob. It was done in a joking manner, when she was joking around, and we were joking around." • She stated that the humping was a "misunderstanding," stating that they joke around a lot amongst themselves, and maybe someone "misheard it." • She denied being aware of anything related to resident #2. AP# 4 was interviewed and video taped by the Albert Lea Police Department on 5/6/2008 (time not documented). Her interview was consistent with the above allegations. In the police interview, she also stated that AP #2 was the one who "humped residents." AP #2 would stand next to a resident and "hump" them." She indicated that AP #2 "would just pretend to hump their leg." She witnessed AP #1 "poke" resident #7 in the breast, and stated that she laughed when the resident got mad. AP #2 would touch resident #12's nose or play with her wig, and she would "get really, really mad, and say, Leave me

Good Sam Society Albert Lea

H5441019

Page 6 of 14

alone." She also stated that AP #2 would also "flick" water at her, and tap resident #12's shoulder from behind to agitate her. She also stated that she had heard that AP #2 "stuck her finger up resident #2's butt, but didn't know if she way trying to get the person to poop, or just doing it as a joke." AP #4 admitted to "joking" with resident #5 by pretending she couldn't hear him talking, which agitated him. AP #3!NA was interviewed on 5/28/2008 at 4:04 p.m. and stated the following: • She stated that she witnessed either AP #1 or #2 spit in resident #1's mouth. She stated that they did it to see his reaction. After they spit, resident #1 was "spitting and moving his mouth around." "They laughed." She was aware of this happening on one occasion. • She stated that she thought it was resident #2 (unsure if right resident, but it was a female resident) that AP #2 "stuck her finger up her butt." She indicated that she wasn't there, but heard her talking about it, and indicated that she was unsure why she did it. • AP #2 "mooned" resident #7. She indicated that she witnessed AP #2 sit on resident #7's lap with her bare butt. She stated that resident #7 was in her wheelchair when AP #2 sat on her lap. • AP #1 stuck her butt in resident #9's face. She indicated that it was not her bare butt, and resident #9 hit at her. AP #3 was a witness to this. • AP #2 got on top of resident #12 when she was in bed, and "humped her a little bit." She indicated that AP #2 was on top of the blanket and she had her clothes on. She was a witness to this, and indicated that resident #12 laughed. She was unsure why AP #2 would do this. • She also stated that resident #15 was always "touchy feely," She would poke at us and touch our butts, and AP #4 "poked her boobs." She indicated that employee #4 poked resident #15 because resident #15 poked her in the butt. • There is a video of resident #5 when his hat fell off, and "I was trying to hand it back to him, and he smacked my hand." She stated that he was angry, and they took a video. She stated that it was only her group of friends that saw the pictures or videos of the residents. • She denied touching resident #5 inappropriately, and only touched his peri area to do his cares. • She stated that she didn't think about reporting any of the incidents, because she didn't want to "rat my friends." AP #3 was interviewed and video taped by the Albert Lea Police Department on 5/6/2008 (time unknown) and verified the above incidents. In the police interview, AP #3 indicated that AP #2 would, at times, lie on and «grope" resident # 12. She also indicated that she witnessed AP #2 put her "bare butt" in resident #7's lap, and "mooned her." She witnessed AP #2 and #1 "poking boobs," and AP #2 "rubbing vigorously" on the peri areas of residents. She stated that AP #1 and #2, did it four or five times with residents, but couldn't remember which residents. She stated that AP #1 "put her bare butt" (she was re-interviewed on 5/812008, and denied that it was AP #1's bare butt) in resident #9's face and indicated that resident #9 hit her. AP #2 poked resident #7's nose over and over, and tapped her cheek repeatedly. AP #3 agreed that it was to make resident #7 upset. AP #21NA was interviewed on 5129/2008 at 1:58 p.m. and stated the following: • She heard of someone spitting in resident #3's mouth. She denied participation in the incident. • Resident #5 gets mad easily if you take his cap off. There was a video on her phone with AP #3 in the room, and AP #3 "might have hit his hat off," and he would yell out and call us "Whore pigs. He started getting really really angry." He was brought into the hall, and then he was calm. She indicated that it was only she and AP #3 who saw the video. • She stated that she did sit on resident #7's lap, but it was to give her a hug. She stated that she had her uniform on.

Good Sam Society Albert Lea

H544l019

Page 7 of 14

• •

She sat on resident #12's bed to give her a hug, and said goodnight. She denied patting or poking her in the breasts. She denied spitting in resident #3's mouth. She denied stimulating a male resident. She admitted to spitting water at resident #12; she stated that she was taking a drink, and someone said something funny, and she spit water on resident #12. She said she was sorry, and went to get something to clean her up. She stated that she was in resident #9's room, and resident #9 was trying to have a bowel movement, and "I stuck my finger in there a little bit, and I pulled it back out, I couldn't deal with it, it feIt wrong." She indicated that she was trying to help stimulate her bowels. She did not report this to the nurse on duty that day. When asked about teasing, she stated that she did tease resident #7. She stated she would put her hand on resident #7's hand, and pull it away, while she tried grabbing it. She stated that she would put her finger on resident #7's nose, and say "boop, boop," to get her to smile.

AP #2 was interviewed and video taped by the Albert Lea Police Department on 5/6/2008 at 2:45 p.m. and admitted to taking resident #5's hat off, and putting it back on him. When asked if it was to antagonize him, she stated, "it could have been." She denied humping residents, or getting in bed with any resident, or sexually arousing any resident. Employee (M)/NA was interviewed on 5/2912008 at 4:00 p.m. and stated the following: • She stated that she witnessed AP #1 "spit in resident #3's mouth." She indicated that she and AP #1 were washing resident #3, and AP #1 said "look at this, and then she just did it, I don't know why." She indicated that resident #3 'just sat there, she didn't really know what was going on." Employee (M) indicated that she didn't think about reporting it, she just walked out of the room, and forgot about it. • She indicated that AP #2 told her that she squirted water at resident #12. They were walking out of work, and AP #2 was "telling me about it." She didn't indicate why she did it. Employee (M) was interviewed and video taped by the Albert Lea Police Department on 51612008 (time unknown) and verified the above incidents. She stated that AP #1 would "poke the residents in the boob," and then the residents would hit her. She also stated that AP #1 would, when washing up a male resident, apply pressure to the genitals when she was washing them up, "just for fun." Employee (U)/nurse was interviewed on 613/2008 at 2:34 p.m. and stated the following: • On Saturday, May 3rd, between 4 and 5 p.m., employee (K) approached her at work, and stated that she had witnessed other employees abusing or doing things to the residents that she didn't think they should be doing. • Some of the resident's have Alzheimer'S, and "they don't understand when you are doing their cares, so they will try to hit you." Employee (K) stated to her that the employees (AP#l, #2, #3, and #4) held the residents' hands down; they would "spit in some of the resident's mouths." They were "flicking at their boobs." She said AP's #1 and #2 "were the ones that did the stuff more often, than the other two." • Employee (K) told her that AP #2 spit in residents' mouths, and AP #2 was the one who flicked residents in the breasts, but AP #2 and AP #1 "held down arms." She told her that her friends would talk about these incidents. • Employee (K) told her "when they would do these things, they would pull the curtain enough, so when they heard a door open, they could stop. They were quite sneaky about what they were

Good Sam Society Albert Lea

H5441019

Page 8 of 14

doing." She indicated that none of the resident's said anything; "the one's they were targeting, were those that have Alzheimer's so bad, that they wouldn't be able to say it or remember." She stated that employee (K) had known for a while, but she didn't know what to do. Employee (K) knew it needed to be reported. In her facility documentation, dated 513/2008, employee (U) indicated that employee (K) told her that employees # I, #2, #3, and #4 talked about "how they hit residents in the boobs, and testicles." These residents include: #9, #4, #3, #6, and #5.

Employee (K)/NA was interviewed on 6/9/2008 at 12:23 p.m. and 6/1112008 at 1: II p.m., and stated the following: • She stated that she had a guilty conscience, and on 5/3/2008, she went to employee (U)/nurse. She stated that she knew she needed to report what she had heard and witnessed. She talked to employee (V), and they called employee (I). Employee (I) told her to write down everything she knew, that night, and the next day employee (K) talked to the administrative staff, and told them what she had witnessed or heard. In her facility documentation, dated 5/3/2008, she indicated that AP #3, #1, #2, and #4 have all "touched resident's breasts, peri area, and also made them more confused." The residents they have done this to include: resident #3, #4, #5, #6, #7, #8, #9, and #10. • She had heard in conversations with her friends, (AP's #1, #2, #4, #3, (M), (V), and (K» about things some of the girls did to the residents at the facility, and indicated that she witnessed abuse on one occasion. These girls were present, at different times, during these conversations. She stated that these were the girls that were normally together outside of work. • She witnessed AP #2 hold her hand over resident #4's mouth, and hold her anTIS and legs down. Resident #4 was resistive, and AP #2 was holding her down to keep her from hitting and kicking. "She was trying to protect us, but she shouldn't have done it." She stated that AP #2 also held her hand over resident #4's mouth to keep her from screaming. It was "kind of' hard, not hard enough to give her a bruise, but to keep her from hitting and kicking. She indicated that resident #4 continued to hit and kick and scream, while she was holding her down. • AP #1 stated that she spit in resident #3's mouth, and she laughed as she was talking about it. She stated that she said, "Guess what happened ... I spit in their mouth." She stated she did it to be funny. In her facility statement, dated 5/3/2008, employee (K) stated that AP #1 and AP #2 talked about spitting in resident #3's mouth. She heard her friends talk about touching the crotch or breasts of residents #2, #3, #10, and #6. "To them it's just a joke, funny, something to amuse you at work, they don't think of it as being bad, they just think of it as a joke." AP's #1 and #2 talked about touching resident #5 in a joking manner. They "rubbed his area, but not his actual penis, by it," "to make him more mad" She stated that his reaction was to get mad and swear. • She heard from AP #2 that AP #1 was rubbing resident #2 in the breasts. She indicated she didn't know why she did this. • Frequently, about once a week, AP #2 talked about holding resident #4's arms and legs down to keep her from hitting and kicking, and hold her hand over resident #4' s mouth, to keep her from screaming, so they could do her cares. • AP #1 would upset resident #6 by saying things to confuse her. Employee (M) gave the example: If resident #6 said: Where am I? AP # 1 would tell her she was in jail, to make her upset. "They think of it as a joke." • AP #2 held resident #8's cheeks together. She stated that she heard AP #1 and #2 talking about it. In her facility report, written 5/3/2008, em~e4!. (K) stated that AP #2 would do this when resident #8 was "agitated and yelling."

Good Sam Society Albert Lea

H5441019

Page 9 of 14

She stated that both AP #1 and #2 talked about holding resident #9's arms and legs down, to keep her from hitting, pinching, and scratching. They would say things to her to confuse her too, and tell her to "shut up" when she was screaming. They would make resident #10 more confused, and #12 more agitated by holding down their arms, and saying things they knew would confuse them, like they did with resident #6. She stated that she told her friends "it was gross and wrong, and they shouldn't do it, you can get in a lot of trouble. You shouldn't treat people like that." "To them, it's just a joke; they don't see it as abuse, or anything." She indicated that they were trained that when the residents' hit and kick, leave them alone, let them "cool down" and go tell the nurse. She stated that they are always supposed to tell the nurse about these incidents.

Employee (K) was interviewed and video taped by the Albert Lea Police Department on 51512008 at 10: 10 a.m. and verified the above incidents. In addition, in the police interview, she also stated that AP #2 talked about spitting in resident #3's mouth, and holding down resident #4's arms and legs to do cares on her. In the police interview, she stated that all four; (AP #1, #2, #3, and #4) would do things to make residents' more confused. She stated that AP #2 put her hand over resident #4'8 mouth, so that she couldn't yell as loudly. Employee (K) stated that she witnessed this on one or two occasions. Employee (K) stated that one time while AP #1 and #2 were doing cares on resident #9, she started to get upset. She stated that AP #1 and #2 poked and hit her breasts, "trying to make her mad." She stated that resident #9 would tell them to stop, but they would 'just laugh" because "they thought it was funny." Employee (K) stated that a11four (AP #1, #2, #3, and #4) when doing cares on someone with dementia or Alzheimer's, would do things to get a "rise out of them." She stated that they would hit their "boobs or crotch or rub it around." She stated that they would do this to make the resident's mad. Employee (K) stated that resident #5 was abused. She stated that AP #1, #3, and #4 would touch his "private parts" to make him mad. She stated when they would touch his private parts; he would "get hard," She stated they were trying to get a "rouse out of him, as in sexual teasing." She stated that both AP #1 and #2 would squeeze resident #8's mouth, so she couldn't yell. She stated that they were "pretty open" about discussing incidents with their own group of friends, outside of work, but not with anyone else. She stated that they talked about the things they were doing, it was "making work fun or to get a good laugh." She stated that the "practice" would be to pull the curtain by the bed, so in case someone knocked and then walked in, they would be behind the curtain. She stated that they were confident that the residents wouldn't complain, because they don't "have their minds." Employee (V)/NA was interviewed on 6126/2008 at 1:21 p.m. and stated the following: • She heard that AP #1 spit in a resident's mouth (unsure which resident). She stated that she "possibly" heard about it from AP #2. She stated that it was talked about when employees (V) and (M), and AP's #2 and #3 were together. • She denied any other conversations or denied witnessing any other incidences. Employee (V)/NA was interviewed and video taped by the Albert Lea Police Department on 5/5/2008 at 2:45 p.m. and stated the following: AP #1, #2, #3, and #4 would "almost get frustrated" with the residents' when they weren't "working with the aides." She stated that at times, they would yell at them, and say, "knock it off." She stated that on one occasion, AP #1 and #2 were upset with resident #3, and "one of them spit" in her mouth. She stated that she didn't know if it was one or both of them that spit. She stated that they were laughing as they told about the incident. She stated that the "girls" would spank resident #11 when he was walking, and he would laugh, so they would keep doing it. She

Good Sam Society Albert Lea

H5441019

Page 10 of 14

also stated that the "girls" would take resident #11 '5 cane, and pretend to ride it like a horse. They would spank him with the cane also. Personnel Files: The AP's personnel files were reviewed and revealed that they all received orientation and training including but not limited to: resident rights, behavior management and problem solving with challenging behaviors, abuse and neglect, mandated reporting of abuse and neglect, and the Vulnerable Adults Act. AP #1's personnel file was reviewed and revealed the following: • She was hired as a nursing assistant on 4/3/2007. She completed all of her orientation and training required for her position as a nursing assistant. She did not have any abuse related disciplinary action in her file, until this incident. • She was suspended from her position on 5/2/2008. AP #2's personnel file was reviewed and revealed the following: • She was hired as a nursing assistant on 8/2212006. She completed all of her orientation and training required for her position as a nursing assistant. She did not have any abuse related disciplinary action in her file, until this incident. • She was suspended from her position on 5/412008. AP #3's personnel file was reviewed and revealed the following: • She was hired as a nursing assistant on 9/11/2006. She completed all of her orientation and training required for her position as a nursing assistant. She did not have any abuse related disciplinary action in her file, until this incident. • She was suspended from her position on 5/412008. AP #4'8 personnel file was reviewed and revealed the following: • She was hired as a nursing assistant on 12/1112007. She completed a11 of her orientation and training required for her position as a nursing assistant. She did not have any abuse related disciplinary action in her file, until this incident • She was suspended from her position on 51412008. AP #5's personnel file was reviewed and revealed the following: • She was hired as a nursing assistant on 6/26/2007. She completed all of her orientation and training required for her position as a nursing assistant. She did not have any abuse related disciplinary action in her file, until this incident. • She was terminated from the facility on 4/30/2008. Conclusion: As defined by federal regulatory requirements at 42 CFR 483.13(b), and the current statutory definition specified within Minnesota Statutes §626.5572, the preponderance of evidence indicates that verbal, sexual, and emotional abuse did occur in connection with the al1egation that four APs verbally, sexually, and/or emotionally abused fifteen residents. Interviews and documentation review established the following: AP#l: • She admitted to the Albert Lea Police Detective that she "spit in resident #3's mouth," but later denied it to the Office of Health Facility Complaints Investigator. She also admitted in the police interview, that she poked resident #9 in the "boobs," and pinched resident #7 in the nipple,

Good Sam Society Albert Lea

H5441019

Page 11 of 14

• •

(on only one occasion) but later denied these occurrences upon interview with the Office of Health Facility Complaints Investigator. AP #5 witnessed AP #1 hit resident #1 in the peri area; poke and hit resident #2 in the breasts; put her fingers in resident #2's mouth; and hit her in the forehead. In the police interview, AP #5 stated she witnessed AP #1 "tap" resident #1 in the genitals, so he would scream. She stated the tap was enough to "hurt any guy, hard enough to make a man cry." She stated that AP #1 "thought that it was funny." Employee (M) witnessed AP #1 spit in resident #3'5 mouth. AP #3 stated that she witnessed either AP #1 or #2 spit in resident #l's mouth (unsure which). Employee (K) stated that she heard AP #1 admit to spitting in resident #3's mouth, and she laughed about it. AP #4 stated that she heard that AP #1 spit in resident #3's mouth. Employee (V) heard that AP #1 spit in a resident's mouth, but was unsure which resident. Employee (K) wrote in a statement, dated 5/3/2008, that AP #1 and AP #2 talked about spitting in resident #3's mouth. Employee (U) wrote in her statement, dated 5/312008, that employee (K) told her that AP #1 and AP #2 have been "bragging about this for the past one to two months." AP #4 stated in the police interview that AP #1 "poked (resident #7) in the breast, and then laughed when the resident got mad." AP #3 witnessed AP #1 stick her butt in resident #9's face. It was not her bare butt, and resident #9 "hit at her." In the police interview, she stated that she witnessed AP #1 "poking boobs," putting her bare butt in resident #7's lap, and "mooned her." Employee (M) (in the police interview) stated that AP #1 would poke the resident's in the breasts, and when washing up a male resident, "apply pressure to the genitals" when she was washing them, 'just for fun." Employee (M) stated that AP #1 talked about touching resident #5 "rubbed by his penis, to make him more mad." AP #1 also talked about rubbing resident #2 in the breasts. AP #1 would hold resident #9' s arms and legs down to keep her from hitting, pinching, and scratching." She would tell her to "shut up" when she was screaming. AP #1 talked about squeezing resident #8's mouth, so she couldn't yell. She also talked about confusing resident #6 "more than she already was, by saying something that would upset her." She stated that AP #1 thought of this as a joke. In the police interview employee (K) stated that resident #5 was abused. Employee (K) heard AP #1 talk about touching resident #5 in his groin area, They "rubbed his area ... but not his actual penis, by it" "to make him more mad." His reaction was to get mad and swear. She stated that AP #1, #3, and #4 would touch his "private parts" to make him mad. She stated that the girls would touch his private parts; and he would "get hard." She stated they were trying to get a "rouse out of him, as in sexual teasing." Employee (K) stated in the police interview, that in mid-January 2008, all four girls (AP #1, #2, #3, and #4) began to tell her things "they'd been doing to residents at the care center." Employee (K) stated that when doing cares on someone with dementia or Alzheimer's, they would do things to get a "rise out of them." She stated that they talked about hitting their "boobs or crotch, or rub it around." She stated that they would do this to make the resident's mad. Employee (K) stated that "all four of the girls mentioned participated in that type of activity." Employee (K) heard from AP #2 that AP #1 was rubbing resident #2 in the breasts. She indicated she didn't know why she did this. In her facility documentation, dated 5/3/2008, employee (K) indicated that AP #3, #1, #2, and #4 have all "touched resident's breasts, peri area, and also made them more confused." The residents they have done this to include: resident #3, #4, #5, #6, #7, #8, #9, and #10.

Good Sam Society Albert Lea

H5441019

Page 12 of 14

AP#2: • She admitted to taking a video of AP #3 in resident #5's room. She stated that resident #5 gets mad if his cap comes off, and AP #3 "might have hit his hat off, and he yelled out and called us, Whore pigs." He got angry, and AP #2 took a video. • AP #2 admitted to sticking her finger up resident #9's rectum, but stated that it was to stimulate a bowel movement. She stated that she did not report this to the nurse on duty. AP #3 and #4 heard about AP #2 sticking her finger up resident #2's rectum, but were unsure if it was to get her to have a bowel movement, or she was just doing it as a joke. • In the police interview, AP #1 stated that AP #2 talked about filling her mouth with water, and spitting it on resident #12. In the police interview, AP #1 also stated that she witnessed that AP #2 "rubbed hard" on resident #2's peri area, and she laughed about it. • AP #1 stated, in the police interview, that she and AP #2 poked resident #9 in the breasts. She stated that AP #2 covered a resident's mouth to keep them from crying out, and about "filling her mouth with water, and spitting it" on resident #12. • AP #4 (in the police interview) stated that AP #2 "humped residents," and that AP #2 would touch resident # 12' s nose or play with her wig, and resident #12 would get "really mad." She also stated that AP #2 would tap resident #12 from behind, to agitate her, and "flick" water at her to make her mad. • AP #3 witnessed AP #2 sit on resident #7's lap with her "bare butt." She also witnessed AP #2 get on top ofresident #12 while she was in bed, and "humped her alittle bit." • In the police interview, AP #3 also stated that she witnessed AP #2 "moon" resident #7. She also witnessed AP #2 "poking boobs, and rubbing vigorously on the peri area of residents." AP #3 stated that AP #2 would lie on and "grope" resident #12, and put her "bare butt" in resident #7'8 lap, and "mooned her." • Employee (K) witnessed AP #2 hold her hand over resident #4's mouth to keep her from screaming, and hold her arms and legs down, to get her cares done quickly. She heard about AP #2 touching resident #5 in his groin area. They "rubbed his area ... but not his actual penis, by it" "to make him more mad." His reaction was to get mad and swear. • Employee (K) stated that AP #2 would try to confuse resident #9, #10, and #12, and hold their anus and legs down to get cares done quickly, and this would agitate the residents. AP #2 poked resident #9 in the breasts, "trying to make her mad, because they thought it was funny." AP #2 would squeeze resident #8's cheeks, so she couldn't yell. • Employee (V), in the police interview, stated that AP's #1 and #2 were upset with resident #3, and "one of them spit in her mouth," She didn't know if it was one or both of them that spit, but indicated that they were laughing as they told of the incident. • AP #5 stated that AP #1 told her that AP #2 would get into bed with the resident's and "hump them." • Employee (K) stated in the police interview, that in mid-January 2008, all four girls (AP #1, #2, #3, and #4) began to teU her things "they'd been doing to residents at the care center." Employee (K) stated that when doing cares on someone with dementia or Alzheimer's, they would do things to get a "rise out of them." She stated that they talked about hitting their "boobs or crotch, or rub it around." She stated that they would do this to make the resident's mad. Employee (K) stated that "all four of the girls mentioned participated in that type of activity." • Employee (K) heard from AP #2 that AP #1 was rubbing resident #2 in the breasts. She indicated she didn't know why she did this.

Good Sam Society Albert Lea

H5441019

Page 13 of 14

• •

Employee (M) also indicated that AP #2 told her that she squirted water on resident #12. Employee (M) stated that she and AP #2 were walking out of work, and AP #2 was talking about it She didn't say why she did it. Employee (K) stated that AP #2 held resident #8's cheeks together. Employee (K) stated that she heard AP's #1 and #2 talking about it. In her facility report, written 5/3/2008, employee (K) stated that AP #2 would do this when resident #8 was "agitated and yelling." AP #5, in the police interview, stated that AP #1 told her that AP #2 would get into bed with the resident's and "hump them." Employee (K), in her facility statement, dated 513/2008, stated that AP # 1 and AP #2 talked about spitting in resident #3's mouth. Employee (U) wrote in her statement at the facility, dated 51312008, that employee (K) told her that AP # 1 and AP #2 have been "bragging about this for the past one to two months." In her facility documentation, dated 5/3/2008, employee (K) indicated that AP #3, #1, #2, and #4 have all "touched resident's breasts, peri area, and also made them more confused." The residents they have done this to include: resident #3, #4, #5, #6, #7, #8, #9, and #10.

AP#3: • AP #2 stated that AP #3 "might have" hit resident #5's hat off. He gets mad easily if you take his cap off, and he hit out, and called us "Whore pigs." She indicated that he was mad, and they took a video. • Employee (K) stated in the police interview, that in mid-January 2008, all four girls (AP #1, #2, #3, and #4) began to tell her things "they'd been doing to residents at the care center." Employee (K) stated that when doing cares on someone with dementia or Alzheimer's, they would do things to get a "rise out of them." She stated that they talked about hitting their "boobs or crotch, or rub it around." She stated that they would do this to make the resident's mad. Employee (K) stated that "all four of the girls mentioned participated in that type of activity." • In the police interview, employee (K) stated that AP #1, #3, and #4 would touch resident # 5 in his "private parts" to make him mad. She stated that the girls would touch his private parts; and he would "get hard." She stated they were trying to get a "rouse out of him, as in sexual teasing." • In her facility documentation, dated 5/3/2008, employee (K) indicated that AP #3, #1, #2, and #4 have all "touched resident's breasts, peri area, and also made them more confused." The residents they have done this to include: resident #3, #4, #5, #6, #7, #8, #9, and #10. AP#4: • AP #4 stated that resident #15 is a very touchy lady, and when asked about poking her in the breasts, she stated, "If she was joking around, and we were joking around, I wouldn't purposely go up to her and poke her in the boob." She indicated that it was done in a joking manner. She indicated that resident #15 would poke at staff, and touch the buttocks of staff, and AP #4 poked resident #15 in the breast, because resident #15 poked her in the buttocks. • Employee (K) stated in the police interview, that in mid-January 2008, all four girls (AP #1, #2, #3, and #4) began to tell her things "they'd been doing to residents at the care center." Employee (K) stated that when doing cares on someone with dementia or Alzheimer's, they would do things to get a "rise out of them." She stated that they talked about hitting their "boobs or crotch, or rub it around." She stated that they would do this to make the resident's mad. Employee (K) stated that "all four of the girls mentioned participated in that type of activity."

Good Sam Society Albert Lea

H5441019

Page 14 of 14

In the police interview. employee (K) stated that AP's #1, #3, and #4 would touch resident # 5 in his "private parts" to make him mad. She stated that the girls would touch his private parts, and he would "get hard" She state they were trying to get a "rouse out of him, as in sexual teasing." In her facility documentation, dated 5/3/2008, employee (K) indicated that AP #3, #1, #2, and #4 have all "touched resident's breasts, peri area, and also made them more confused." The residents they have done this to include: resident #3, #4, #5, #6, #7, #8, #9, and #10.

The facility has policies and procedures in place in regard to abuse prevention. The procedures were followed and implemented after the incidents were made known. Upon report of the abuse to the administrative staff, the facility initiated an internal investigation, and the APs were immediately suspended. The facility brought in a team of nurses to do a head to toe examination of all residents, on the units involved, interviewed all interviewable residents to see if they are provided good care, and to see if they have any concerns. They also interviewed all staff, and asked about any concerns, and reminded them that they are mandated reporters. The facility also held mandatory training for all staff regarding the Vulnerable Adults Act, and reporting of abuse and neglect. The corporate office sent in a team of staff to ensure that the residents at the facility were in a safe environment, and that the administrative staff had additional staff to aid in the investigation. This corrective action had been taken prior to the site investigation, therefore no federal deficiencies or state licensing orders are issued. The "mitigating factors" in Minnesota Statutes, §626.557, subdivision 9c (c) were considered and it was determined that AP #1, #2, #3, and #4 are responsible for the abuse. The AP's will be notified of the right to request reconsideration and/or appeal the maltreatment finding. Since the allegations of maltreatment by identified employees are substantiated, this report will be submitted to the nurse aide registry for possible inclusion of the findings on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements in State law. The employees will be notified of the right to request reconsideration and a hearing to challenge these findings. xc: Division of Compliance Monitoring - Licensing & Certification Minnesota Board of Examiners for Nursing Home Administrators Albert Lea City Police Department Freeborn County Attorney Albert Lea City Attorney

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVlDER/SUPPLIER/CllA IDENTIFICATION NUMBER:

PRINTED: 08/14/2008 FORM APPROVED

OMS NO. 0938-0391
(X2) MULTIPLE A. BUILDING B WING
_ CONSTRUCTION (X3) DATE SURVEY COMPLETED

245441
NAME
OF PROVIDER OR SUPPLIER

C 0511212008
ZIP CODE

STREET

ADDRESS,

CITY, STATE,

GOOD SAMARITAN
(X4) 10
PREFIX TAG

SOCIETY - ALBERT

LEA
ID PREFIX TAG

75507 240TH STREET ALBERT LEA, MN 56007
(X5) COMPLETION DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

F 000 : INITIAL COMMENTS An Abbreviated Standard Survey was conducted . to investigate complainant #H5441019. No deficlencies were noted.

FOGO

!
LABORATORY DIRECTORS OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE
(X6) DATE

Any deficiency statement ending with an asterisk (.) denotes a deficiency which the institution may be excused from conecting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disdosable 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 CM5-2567(02-99) Previous Versions Obsolete

Event 10: VGV511

Facility 10: 00131

If continuation sheet Page 1 of 1

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->