Aging Gracefully

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of two sampled employees. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411.A states, "... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work..." 2. A review of E2's personnel record revealed a hire date of August 21, 2024. E2's personnel record revealed a fingerprint clearance card issued by the Department of Public Safety (DPS) on April 23, 2019, with an expiration date of April 23, 2025. 3. A review of the DPS fingerprint clearance card database, revealed E2's fingerprint clearance card was invalid. 4. A.R.S. \'a7 36-411.F states "An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card." 5. A review of R1's medical record revealed an incident report dated August 19, 2024. The report stated "[R1] mentioned to [E1] that [R1] does not like [E2] because [E2] was acting inappropriately. [R1] said [E2] was dressing [R1] and rubbed across [R1's] [genitalia]." 6. A review of the police report dated August 21, 2024 revealed that R1 had "yellow bruising" on R1's inner upper thigh. A further look into the police report stated, "[E2] had come into [R1's] room on 8/20/2024..." and "... [E2] pretended to assist [R1] getting dressed by pulling up [R1's] pants. As [E2] was pulling up [R1's] pants, [E2] inserted [E2's] finger in [R1

Based on documentation review, record review, and interview, the manager, failed to report the suspected abuse of the resident according to A.R.S. \'a7 46-454(A). The deficient practice posed a risk as the facility did not immediately report suspected abuse of a resident by a personnel member. Findings include: 1. A.R.S.\'a7 46-454(A) "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit." 2. R9-10-101.111 "Immediate" means without delay. 3. A review of R1's medical record revealed an incident report dated August 19, 2024. The report stated "[R1] mentioned to [E1] that [R1] does not like [E2] because [E2] was acting inappropriately. [R1] said [E2] was dressing [R1] and rubbed across [R1's] [genitalia]." 4. A review of the police report revealed the date the police were contacted was August 21, 2024. 5. A review of the police report dated August 21, 2024 revealed that R1 had "yellow bruising" on R1's inner upper thigh. A further look into the police report stated, "[E2] had come into [R1's] room on 8/20/2024..." and "... [E2] pretended to assist [R1] getting dressed by pulling up [R1's] pants. As [E2] was pulling up [R1's] pants, [E2] inserted [E2's] finger in [R1's] [genitalia]." 6. In an interview, E1 acknowledged that a peace officer or Adult Protective Services was not contacted immediately as required in A.R.S. \'a7 46-454(A).

Based on record review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a resident rights violation if the resident was subjected to abuse. Findings include: 1. A review of R1's medical record revealed an incident report dated August 19, 2024. The report stated "[R1] mentioned to [E1] that [R1] does not like [E2] because [E2] was acting inappropriately. [R1] said [E2] was dressing [R1] and rubbed across [R1's] [genitalia]." 2. A review of the police report dated August 21, 2024 revealed that R1 had "yellow bruising" on R1's inner upper thigh. A further look into the police report stated, "[E2] had come into [R1's] room on 8/20/2024..." and "... [E2] pretended to assist [R1] getting dressed by pulling up [R1's] pants. As [E2] was pulling up [R1's] pants, [E2] inserted [E2's] finger in [R1's] [genitalia]." 3. In an interview, E1 acknowledged residents were not treated with dignity, respect, and consideration.