Phoenix Mountain Post Acute

Based on resident, resident representative, and staff interviews and facility documentation, the facility failed to protect the resident's (#11) right to be free from sexual abuse by a staff. The deficient practice could result in residents' increase risk of further harm and abuse.

Findings include:

Resident #11 admitted to the facility on 09/24/2023 and discharged on 02/22/2024 with diagnoses that included Wernicke's encephalopathy, anxiety, post-traumatic stress disorder, migraines, major depressive disorder, and suicidal behavior.

The care plan initiated on 09/25/2023 indicated she preferred a female caregiver relation to her risk of re-traumatization related to a history of intimate partner violence. On 02/01/2024, a goal was initiated for potential for a psychosocial well-being problem related to an inappropriate relationship with a non-caregiving associate as evidenced by Anxiety, depression, and suicidal ideation. Interventions included consultations with pastoral care, social services, and psychiatric services as well as monitoring and documenting residents' feelings related to posttraumatic stress disorder (PTSD) and the termination of the same inappropriate relationship.

The Admission Minimum Data Set (MDS) assessment on 10/01/2023, she scored a 13 on her Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact. She did not exhibit any behaviors in the look back period.

The physician order dated 11/28/2023 revealed an order for trazodone (anti-depressant) 50 mg (milligrams) for inability to fall and stay asleep related to depression.

Resident #1 had orders for the following psychotropic medications: Escitalopram 10 milligrams (mg) for depression dated 10/27/2023 and increased to 20mg on 11/29/2023, trazadone 50mg for inability to fall and stay asleep related to depression dated 11/28/2023 increased to 100mg on 01/22/2024 and increased to 150mg on 02/09/2024, Lorazepam 0.5mg for anxiety dated 10/03/2023.

The Quarterly MDS from 12/13/2023, her BIMS was 15 which indicated no cognitive impairment.

The physician order dated 1/22/2024 revealed the order for trazodone was increased from 50 mg to 100 mg for depression.

The psychiatric note dated 02/01/2024 revealed resident #11 was assessed for trauma regarding a potentially inappropriate relationship between the resident and non-caregiving staff member. Per the documentation, the resident had also reported this to leadership that day; and that, resident #11 told the provider that all the interactions with the staff member (#20) were entirely voluntary and consensual. The plan was for resident #11 to continue her psychiatric medications as currently prescribed and he would follow up with her in 1-2 weeks.

A progress note dated 02/01/2024 by the Interdisciplinary Team (IDT) documented the discussion of concerns regarding an inappropriate relationship between the resident and a non-caregiving staff member.

The skin assessment completed on 02/01/2024 documented light bruising to left upper inner thigh, but indicated the resident reported that she got it from her brief.

The clinical record revealed that on 02/01/2024 the provider ordered a pregnancy test and labs for sexually transmitted diseases (STD) which included herpes (virus), hepatitis (virus), HIV (human immunodeficiency virus), and chlamydia (bacteria).

The clinical record also revealed an order for change of condition related to psychosocial well-being dated 02/01/2024 with the instructions to monitor for increased anxiety/depression and potential for suicidal ideation.

The facility self-report with a date of discovery of 02/01/2024 revealed that on 02/01/2024, the resident reported a relationship between her and a male staff member (staff #20) to the administrator and DON (Director of nursing). Per the report the resident reported that the relationship was consensual; and that, it had involved oral sex on two occasions. It also included that the resident denied engaging in intercourse with staff #20. The report included a summary of the two interviews conducted with resident #11 by the DON. The summary included that the resident reported exchanged phone numbers with staff #20 and they would often text message back and forth; the relationship progressed into kissing and touching a few weeks after the text messages started; the resident and staff #20 had "oral sex (both her for him and him for her)" on two separate occasions (once in the shower and once in the resident's room) both times during the overnight shift. The summary also included that staff #20 shared that he was having financial hardships and the resident offered him help; but the resident confirmed that she never actually gave him money. The summary included that the resident reported she was not forced to engage in this conduct and there were no threats or promises were made by staff #20 to her.

Continued review of the facility self-report included a summary of a phone interview conducted with staff #20 by the DON and the administrator on 02/01/2024. Per the documentation, staff #20 admitted that he exchanged telephone numbers with the resident; and that, he and the resident talked via text message. The documentation included that staff #20 denied any physical contact including but not limited to oral sex; and denied speaking with the resident regarding any financial hardships.

Further review of the facility self-report included that the facility concluded there were no patterns or instances of any other unprofessional or inappropriate relationships; and there were no staff interviewed had witnessed or were aware of any improper conduct or relationship as between staff and resident. It also included that while the facility determined that the relationship between the resident and the staff member was inappropriate and unprofessional, it did not constitute "abuse" as that term is defined in the State's Adult Protective Services statute.

The labs results completed on 02/02/2024 revealed negative for STD.

The psychiatric consultation note dated 02/08/2024 revealed Resident #11 told the provider her mood was "even heavier" and her anxiety had increased since her last visit; and, her sleep had been interrupted, causing her to wake several times per night and making her want to sleep more during the day. It also included that the provider increased her trazodone to address the insomnia as well as the increased depression symptoms.

The psychiatric consultation note dated 02/15/2024 included that Resident #11 reported that she continued to experience feelings of sadness and was having thoughts that she would be "better off gone".

Another psychiatric consultation note dated 02/22/2024 revealed the resident reported that she was transferring to a different facility soon, was optimistic about the move; and that, she had a decrease in all behavioral symptoms.

Review of the personnel file for staff #20 revealed that a job description dated 8/31/2023 and that staff #20 was a certified nurse assistant (CNA). Further, the telephone number on record matched the telephone number that was on resident #11's phone and text messages. It also included that staff #20 signed a job description for laundry staff on 01/05/2024.

A review of punch details for October 2023 to February 2024 revealed that Staff #20 worked as a nursing assistant from 10/01/2023 through 12/25/2023; and, from 01/01/2024 through 01/31/2024, staff #20 worked as a housekeeping aide.

The report submitted by the resident's family to the State Agency complaint portal on 5/13/2024 revealed that resident #11 still had times where she breaks down crying and had told the family member multiple times about the incidents of sexual abuse by an unlicensed caregiver. The report identified the staff involved by name (staff #20); and tha

Based on resident, resident representative, and staff interviews and facility documentation, the facility failed to ensure one resident (#11) was not subjected to sexual abuse by a staff.

Findings include:

Resident #11 admitted to the facility on 09/24/2023 and discharged on 02/22/2024 with diagnoses that included Wernicke's encephalopathy, anxiety, post-traumatic stress disorder, migraines, major depressive disorder, and suicidal behavior.

The care plan initiated on 09/25/2023 indicated she preferred a female caregiver relation to her risk of re-traumatization related to a history of intimate partner violence. On 02/01/2024, a goal was initiated for potential for a psychosocial well-being problem related to an inappropriate relationship with a non-caregiving associate as evidenced by Anxiety, depression, and suicidal ideation. Interventions included consultations with pastoral care, social services, and psychiatric services as well as monitoring and documenting residents' feelings related to posttraumatic stress disorder (PTSD) and the termination of the same inappropriate relationship.

The Admission Minimum Data Set (MDS) assessment on 10/01/2023, she scored a 13 on her Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact. She did not exhibit any behaviors in the look back period.

The physician order dated 11/28/2023 revealed an order for trazodone (anti-depressant) 50 mg (milligrams) for inability to fall and stay asleep related to depression.

Resident #1 had orders for the following psychotropic medications: Escitalopram 10 milligrams (mg) for depression dated 10/27/2023 and increased to 20mg on 11/29/2023, trazadone 50mg for inability to fall and stay asleep related to depression dated 11/28/2023 increased to 100mg on 01/22/2024 and increased to 150mg on 02/09/2024, Lorazepam 0.5mg for anxiety dated 10/03/2023.

The Quarterly MDS from 12/13/2023, her BIMS was 15 which indicated no cognitive impairment.

The physician order dated 1/22/2024 revealed the order for trazodone was increased from 50 mg to 100 mg for depression.

The psychiatric note dated 02/01/2024 revealed resident #11 was assessed for trauma regarding a potentially inappropriate relationship between the resident and non-caregiving staff member. Per the documentation, the resident had also reported this to leadership that day; and that, resident #11 told the provider that all the interactions with the staff member (#20) were entirely voluntary and consensual. The plan was for resident #11 to continue her psychiatric medications as currently prescribed and he would follow up with her in 1-2 weeks.

A progress note dated 02/01/2024 by the Interdisciplinary Team (IDT) documented the discussion of concerns regarding an inappropriate relationship between the resident and a non-caregiving staff member.

The skin assessment completed on 02/01/2024 documented light bruising to left upper inner thigh, but indicated the resident reported that she got it from her brief.

The clinical record revealed that on 02/01/2024 the provider ordered a pregnancy test and labs for sexually transmitted diseases (STD) which included herpes (virus), hepatitis (virus), HIV (human immunodeficiency virus), and chlamydia (bacteria).

The clinical record also revealed an order for change of condition related to psychosocial well-being dated 02/01/2024 with the instructions to monitor for increased anxiety/depression and potential for suicidal ideation.

The facility self-report with a date of discovery of 02/01/2024 revealed that on 02/01/2024, the resident reported a relationship between her and a male staff member (staff #20) to the administrator and DON (Director of nursing). Per the report the resident reported that the relationship was consensual; and that, it had involved oral sex on two occasions. It also included that the resident denied engaging in intercourse with staff #20. The report included a summary of the two interviews conducted with resident #11 by the DON. The summary included that the resident reported exchanged phone numbers with staff #20 and they would often text message back and forth; the relationship progressed into kissing and touching a few weeks after the text messages started; the resident and staff #20 had "oral sex (both her for him and him for her)" on two separate occasions (once in the shower and once in the resident's room) both times during the overnight shift. The summary also included that staff #20 shared that he was having financial hardships and the resident offered him help; but the resident confirmed that she never actually gave him money. The summary included that the resident reported she was not forced to engage in this conduct and there were no threats or promises were made by staff #20 to her.

Continued review of the facility self-report included a summary of a phone interview conducted with staff #20 by the DON and the administrator on 02/01/2024. Per the documentation, staff #20 admitted that he exchanged telephone numbers with the resident; and that, he and the resident talked via text message. The documentation included that staff #20 denied any physical contact including but not limited to oral sex; and denied speaking with the resident regarding any financial hardships.

Further review of the facility self-report included that the facility concluded there were no patterns or instances of any other unprofessional or inappropriate relationships; and there were no staff interviewed had witnessed or were aware of any improper conduct or relationship as between staff and resident. It also included that while the facility determined that the relationship between the resident and the staff member was inappropriate and unprofessional, it did not constitute "abuse" as that term is defined in the State's Adult Protective Services statute.

The labs results completed on 02/02/2024 revealed negative for STD.

The psychiatric consultation note dated 02/08/2024 revealed Resident #11 told the provider her mood was "even heavier" and her anxiety had increased since her last visit; and, her sleep had been interrupted, causing her to wake several times per night and making her want to sleep more during the day. It also included that the provider increased her trazodone to address the insomnia as well as the increased depression symptoms.

The psychiatric consultation note dated 02/15/2024 included that Resident #11 reported that she continued to experience feelings of sadness and was having thoughts that she would be "better off gone".

Another psychiatric consultation note dated 02/22/2024 revealed the resident reported that she was transferring to a different facility soon, was optimistic about the move; and that, she had a decrease in all behavioral symptoms.

Review of the personnel file for staff #20 revealed that a job description dated 8/31/2023 and that staff #20 was a certified nurse assistant (CNA). Further, the telephone number on record matched the telephone number that was on resident #11's phone and text messages. It also included that staff #20 signed a job description for laundry staff on 01/05/2024.

A review of punch details for October 2023 to February 2024 revealed that Staff #20 worked as a nursing assistant from 10/01/2023 through 12/25/2023; and, from 01/01/2024 through 01/31/2024, staff #20 worked as a housekeeping aide.

The report submitted by the resident's family to the State Agency complaint portal on 5/13/2024 revealed that resident #11 still had times where she breaks down crying and had told the family member multiple times about the incidents of sexual abuse by an unlicensed caregiver. The report identified the staff involved by name (staff #20); and that, the resident had now frightening nightmares on what took place and had been disgusted with h