Does the story behind sexual abuse cases help or harm your case? LNCs and attorney focus on the critical intricacies of nursing home abuse cases, as detailed in the chapter Torn Veils of Protection: The Hidden Challenges of Sexual Abuse Cases in Nursing Homes in Medical Record Analysis, volume 3.
Deneene Bradford emphasizes the investigative process, including the crucial role of detailed documentation and the legal insights necessary for addressing egregious failures in care.
Sexual Abuse Case Study 1
Wanda Jackson was an 85-year-old female, with a past medical history (PMH) of unspecified dementia, generalized weakness, abnormality in mobility (difficulty walking), and hypertension. The paramedics transported her from a skilled nursing home to the emergency department (ED) for a chief complaint of sexual assault.
The physical examination by the emergency department staff revealed a moderate amount of white discharge in her vagina and abrasions indicating evidence of sexual penetration.
Background
Ms. Jackson was admitted to the skilled nursing home approximately two years before her alleged sexual assault. On admission, the facility staff assessed her as being at risk for abuse.
Ms. Jackson’s latest Minimum Data Set (MDS) showed that she required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, bathing, and locomotion on the unit. She required the use of a wheelchair for mobility. Her brief interview for mental status (BIMS) score was eight (moderately impaired cognition).
Around 2:30 AM, Maria Vasquez, Certified Nurse Assistant (CNA) heard screaming down the hallway near Ms. Jackson’s bedroom. When she walked down the hallway, CNA Vasquez found out that it was Ms. Jackson screaming. When CNA Vasquez arrived at Ms. Jackson’s bedroom, she saw John Thomas (another resident) on top of Ms. Jackson in her bed. Mr. Thomas had his pants down around his knees and his shoes were off. Ms. Jackson’s gown was up around her waist and her legs were open. Mr. Thomas was having sex with her.
When CNA Vasquez saw what Mr. Thomas was doing, she told him to get off Ms. Jackson. Mr. Thomas complied and started to pull up his pants and put on his shoes. CNA Vasquez walked to Ms. Jackson’s bedroom door and called the nurse, Julie Wang.
John Thomas was a 65-year-old male, with a past medical history (PMH) of dementia with behavior disturbances, unspecified psychosis, anxiety, and personal history of inappropriate sexual behavior toward others. He was admitted to the skilled nursing home approximately one year before the alleged sexual assault. His latest Minimum Data Set (MDS) showed that he was independent with walking, dressing, eating, toilet use, personal hygiene, and bathing. His brief interview for mental status (BIMS) score was 11 (moderately impaired cognition).
Upon entering Ms. Jackson’s bedroom, Nurse Wang saw Mr. Thomas walking out of Ms. Jackson’s bedroom, with his clothes on. She noted Ms. Jackson lying in her bed, partially disrobed, with her legs open. Ms. Jackson had tears in both eyes and a small amount of bright red drainage at the opening of her vagina. Nurse Wang closed Ms. Jackson’s legs, pulled her gown down, and covered her with her bedsheets and a blanket.
CNA Vasquez left to perform her required duties for her other assigned residents. Nurse Wang then left Ms. Jackson’s bedroom and called Melissa Harris, the administrator, Rachael White, the director of nursing (DON), and Dr. Mark Rodgers. Dr. Rodgers ordered the staff to send Ms. Jackson to the local emergency department for an evaluation and a rape kit. Administrator Harris instructed Nurse Wang to put Mr. Thomas on 15-minute checks at approximately 3:00 AM. Mr. Thomas’s bedroom was at the opposite end of the adjacent hallway. Ms. Jackson went to the emergency department around 3:45 AM, where the ED Sexual Assault Nurse Examiner used a rape kit to collect deoxyribonucleic acid (DNA) evidence.
The next day, Administrator Harris reviewed the video footage which showed that Mr. Thomas went into Ms. Jackson’s bedroom at 2:10 AM and CNA Vasquez went into her room at 2:30 AM. In addition, the footage also showed that Mr. Thomas returned to his bedroom around 2:45 AM. None of the staff went into Mr. Thomas’s bedroom or sat outside his bedroom continuously from 2:45 AM until the end of the shift at 7:00 AM. The medical record showed that CNA Vasquez checked on Mr. Thomas at 4:00 AM and 6:00 AM.
Administrator Harris and Ms. White, DON arrived at the facility around 8:00 AM (five-and-a-half hours after being notified of a sexual assault that happened in the facility). When they got to the facility, a local police officer was there. The emergency department staff at the hospital had called the local police department to report the alleged sexual assault in the facility. The officer collected evidence from Ms. Jackson’s bedroom and looked at the video footage with the administrator.
On the next shift (7AM – 3PM), around 8:15 AM, Nurse Kathleen Blake noted Mr. Thomas standing at the nurse’s station. Nurse Blake asked him to go to his bedroom or the dining room to eat breakfast; he refused. Video footage showed Mr. Thomas walked to the residents’ activity room, dining room, the nurse’s station, and back to his bedroom several times during the shift. He was around multiple female and male residents.
None of the staff on the next shift performed 15-minute checks on Mr. Thomas. Around 2:00 PM, (11 ½ hours after the incident) Mr. Thomas was again in the activity room again around multiple other residents. Nurse Blake asked him to go to his bedroom again. He became agitated and shouted, “Leave me alone. I have a right to be here” at the staff. The staff was unable to re-direct him. Nurse Blake called Dr. Rodgers, who ordered Mr. Thomas to be sent to the local emergency department for an evaluation. The staff arranged transport for Mr. Thomas to go to the emergency department at 3:00 PM (12 ½ hours after the incident).
The video footage also showed the facility staff did not provide any continuous monitoring for Mr. Thomas. He was allowed to walk around the facility and other residents without any continuous supervision or monitoring. When interviewed later, Christina Martinez, CNA, Jackie Lee, CNA, and Theresa Scott, CNA, all stated that they did not continuously monitor Mr. Thomas during the shift. CNA Scott also stated that she was assigned to Mr. Thomas for the shift. She checked on him twice during the shift, around 10 AM and 12:30 PM.
Ms. Jackson returned to the facility from the hospital around 4:00 PM with a diagnosis of sexual assault. Upon return to the facility, when Audrey Hicks, CNA, asked Ms. Jackson if anyone had hurt her, she pointed to her genitals and stated, “Yes.” She was not able to provide specific details.
Mr. Thomas returned to the facility around 11:00 PM. ED staff took DNA while he received treatment in the hospital. He was placed on one-to-one supervision by Michael Anderson, CNA, and in a single bedroom upon his return to the facility.
At 1:00 AM a local police officer arrived at the facility to provide one-to-one supervision for Mr. Thomas. Around 9:00 AM, when the DNA test results were obtained, Mr. Thomas was arrested for sexual assault.
The Department of Public Health Surveyor investigated this sexual abuse incident and reviewed this documentation:
- The facility’s incident report and investigation
- Jackson’s nursing notes
- Jackson’s current physician order sheet
- Jackson’s monthly primary physician progress notes
- Jackson’s latest MDS assessment
- Jackson’s social service screening related to risk for abuse
- Jackson’s hospital records
- Police Report
- Thomas’s current physician order sheet
- Thomas’s monthly primary physician progress notes
- Thomas’s psychiatric physician notes
- Thomas’s nursing notes
- Thomas’s latest MDS assessment
- Thomas’s behavior plan
- Thomas’s care plan for history of inappropriate sexual behaviors toward others and evidence of implemented interventions.
- Thomas’s hospital records
- Thomas’s background check
- Staff schedules and resident assignments (shift incident occurred on and until Mr. Thomas went for an emergency room evaluation)
- The facility’s abuse allegations
- The facility’s abuse policy
- The facility’s video footage
- The documentation for guardian and regulatory agency notification of a sexual abuse allegation
Read the rest of this story in Medical Record Analysis, Vol. 3.
Pat Iyer is president of The Pat Iyer Group, which develops resources to assist LNCs in obtaining more clients, making more money, and achieving their business goals and dreams.
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