Goodyear skilled nursing facility fined after resident alleges she was raped, impregnated
A nursing assistant is accused of raping, and impregnating, a resident at a skilled nursing facility in Goodyear. The story is reminiscent of what happened at the Hacienda HealthCare intermediate care facility in Phoenix more than five years ago, when an incapacitated woman was raped and later gave birth.
While the latest events are still under investigation, records from the Arizona Department of Health Services reveal that the resident says she was raped multiple times and that some staff were aware or heard rumors and failed to report it immediately.
After Hacienda, a task force on abuse and neglect was formed in 2019. From it, 30 recommendations were issued and, had they all been implemented, should have prevented what happened.
"One hundred percent. And that's, I think that's where the biggest frustration lies," said Ann Monahan, who was on the task force.
Her colleague Diedra Freedman was part of a task force working group.
"I was very disappointed," said Freedman, who added that the task force's recommendations "were watered down in the final report."
Freedman called the recommendations aspirational. Meantime, Goodyear police are investigating.
The alleged perpetrator was fired and has since voluntarily surrendered his license as a certified nursing assistant.
Emma Mamaluy is the chief counsel for the Arizona State Board of Nursing.
"He admitted to having sexual relations with the patient. There was his position that it was consensual, and that she had actually initiated the sexual intercourse. However, for us, that would still be a violation."
According to reports from the state health department, the alleged victim told investigators that she was repeatedly raped. The facility was fined $2,000 by the state for failing to ensure a resident was free from sexual abuse from staff and ensuring allegations of sexual abuse were thoroughly investigated, among other violations.
Statement on the case from the Arizona Department of Health Services
Some of our findings, which are posted in entirety on AZCareCheck.com, were as follows:
Based on observations, clinical record review, resident and staff interviews, review of facility documentation, policy and procedures the facility failed to ensure one resident (#38) was free from sexual abuse from staff. The deficient practice resulted in psychosocial harm to resident #38 and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SOC) were identified.
Based on documentation provided to the department, we found that although the facility was notified of the alleged abuse on November 3, 2023, there was no evidence that the alleged perpetrator was suspended until November 13, 2023.
Despite the special instruction in the care plan of having care in pairs, there was no evidence found in the facility documentation and investigation that another staff member was present in the room when the alleged perpetrator entered the room of the alleged victim.
We cited the facility for the following violations, in addition to other deficiencies, unrelated to the alleged assault:
R9-10-410.B.3.a. An administrator shall ensure that: A resident is not subjected to Abuse
R9-10-403.C.2.b. Policies and procedures for physical health services and behavioral health services are established, documented, and implemented to protect the health and safety of a resident that: Cover the provision of physical health services and behavioral health services;
R9-10-403.F.5.a If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe that abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from a nursing care institution's employee or personnel member, an administrator shall: Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (F)(2) that includes: The dates, times, and description of the suspected abuse, neglect, or exploitation;
The facility self-reported the incident to ADHS on 11/18/23.
The alleged perpetrator was terminated on 11/20/23. Federal regulators will now determine proper financial penalties for the facility. We reported the incident to the Board of Nursing and are collaborating with Goodyear Police and Adult Protective Services for further investigation.
Statement from the skilled nursing facility
“The care and well-being of our patients is Palm Valley’s top priority, and we regret that this situation has occurred," said Dan Kramer, Palm Valley spokesperson.
"It’s important for the community to know that, from the outset, we have sought to take a transparent and proactive approach to addressing this issue. Our efforts began with an internal investigation on the day this first came to our attention, and those efforts continue today with our ongoing cooperation with the authorities as they complete their investigations, as well as personal updates for our patients and families, and additional training and education for our staff. Our internal investigation included interviews with those allegedly involved or who may have had knowledge of the allegations. No one we interviewed, including the former patient, suggested that the allegations had any merit. As more information became available, we suspended the former employee and subsequently terminated them. The AZ Dept. of Health Services and CMS have confirmed that Palm Valley is back in compliance, and due to personal privacy restrictions, we cannot provide any further information about the former patient, who has not been named publicly, and whose identity should be protected.”
