AZDHS: Long-term care facility waited weeks to report patient's rape, pregnancy

GOODYEAR, Ariz. - We want to warn you many of the details we’ve uncovered are sexually graphic.

A former Arizona nursing assistant is under criminal investigation and is accused of raping a patient and getting her pregnant at a long-term care facility.

FOX 10 uncovered new details about how it took several weeks for state agencies to find out about the alleged sexual abuse. We've also learned the Goodyear Police Department is investigating the man accused in this case.

Back in January, the suspect, Bobby Lee Williams, voluntarily surrendered his certified nursing assistant license which he had just received last June.

Why?

Documents say Williams admitted to having sex with a patient at Palm Valley Post Acute, but told the board’s investigator it was consensual and "she came onto me."

In late November 2023, the nursing board received two complaints about Williams. One from Arizona's Department of Health Services (AZDHS) and one from staff at Palm Valley.

"The board takes that very seriously. It is not allowed. There’s a specific rule against any nurse or nursing assistant having sexual relations with a patient," said Emma Mamaluy with the Arizona State Board of Nursing.

Records we found through AZDHS reveal the alleged victim tried to tell the facility’s director of operations that she was raped but was ignored and told to "follow the chain of command."

It was discovered the patient was impregnated.

‘Facility failed to implement policy’ to protect a resident, AZDHS says

Just days before the state’s board of nursing was notified, Arizona DHS conducted a week-long investigation into the alleged sexual abuse at Palm Valley Post Acute.

AZDHS found several deficiencies, saying the "facility failed to implement policy" to protect a resident and failed "reporting and investigating allegations of sexual abuse."

The 60-page "statement of deficiencies" refers to the alleged victim as "resident number 38." The former certified nursing assistant now under investigation is referred to as "staff number 17" in documents.

Documents say resident 38 came to Palm Valley last September with a diagnosis of disrupted blood flow to the brain, post-concussion syndrome, anxiety disorder and an unspecified head injury.

On Nov. 17, 2023, an investigator with AZDHS interviewed the alleged victim who said she woke up to Williams kissing her before he sexually abused her last September.

Resident 38 said this was the third or fourth time Williams raped her, according to the AZDHS report.

Note: Below is a document detailing graphic allegations against Williams. Please use discretion when reading.

Documents say after getting a roommate, listed as resident 17, the victim texted her sister that "God was looking out for her" and that maybe Williams "would not rape her anymore."

The next day, the victim said another Palm Valley employee walked into her room and caught Williams on top of her.

Findings reveal the alleged victim told AZDHS that when she drank a soda Williams brought her, she could not move but was awake.

She also stated that Williams raped her after she took medication because she would be "tired."

Ultimately, the patient claimed Williams raped her 15–20 times and that "the incident replays in her head over and over," documents say.

'Could have dug deeper on the incident’

A spokesperson for Palm Valley Post Acute sent a statement to FOX 10, saying in part, "We take our patients’ safety, security and wellness seriously. We’re aware of the allegations against a former employee, and it is important for the community to know that the individual in question was swiftly terminated after we learned of the allegations. We self-reported the issue to the appropriate officials and are complying with all investigations."

However, AZDHS findings say despite knowing about allegations of sexual abuse as early as last September, there is no evidence found that it was reported to a state agency until Nov. 18, 2023.

Palm Valley’s administrator said he "should have done a better job completing a thorough investigation and reporting," going on to say the facility "could have dug deeper on the incident."

Palm Valley’s statement doesn’t say when staff learned of the allegations but documents FOX 10 obtained say resident 38 tried speaking with the director of operations in late September of last year, but she was allegedly told to "follow the chain of command" even though another nursing assistant reported the same incident to the facility’s director of nursing on Sept. 28.

DHS findings say despite knowing about allegations of sexual abuse, there is no clinical record or evidence that Palm Valley reported anything to a state agency until Nov. 18, 2023. A day prior, a concerned staff member called AZDHS to report the alleged abuse.

On that same day, the report was sent to Adult Protective Services and Goodyear Police.

Per DHS records, it took a letter from a law firm representing the alleged victim for Williams to be fired on Nov. 20. He was suspended a week earlier, without pay.

When Williams was interviewed on Nov. 18 of last year, documents say he thought the relationship was consensual because resident 38 "pursued him with sexual conversations and "made the first physical contact."

The facility’s report concluded that this was a "consensual relationship" and "no sexual abuse" happened.

The alleged victim notified Goodyear PD on Oct. 13 of last year.

The Goodyear Police Department will not comment further besides telling FOX 10 that there is an active investigation into the former nursing assistant and updates will be shared when available.

Similar case reported on in 2019 at a different facility

This story isn't to be confused with the 2019 case at Hacienda Healthcare when Arizona health and law enforcement agencies investigated a case of sexual abuse after a baby was born to a patient that had been in a vegetative state for several years.

In the end, in 2021, Nathan Sutherland pleaded guilty to sexual abuse and vulnerable adult abuse charges. He's serving a 10-year sentence.

Palm Valley releases statement on AZDHS report

"Palm Valley’s investigation began on Sept. 28 and included an interview with the former patient. The internal investigation did not uncover any evidence of inappropriate behavior between the patient and the CNA. The Dept. of Health Services investigated on Oct. 31 and found the claims unsubstantiated as well. Due to the facility’s ongoing efforts, the former employee was subsequently suspended prior to the department returning weeks later for a second investigation, which followed the former patient’s filing of a complaint with local law enforcement. At that time, the department issued four citations. It was also at that time that the former employee was terminated. Because the department uses different citation tag numbers than CMS, the four citations are each listed twice. The department and CMS have confirmed that the facility is back in compliance. Due to personal privacy restrictions, we cannot provide any further information about the former patient or specifics about our investigation. We regret that the situation has occurred, as our patients’ care and well-being are always our top priority. We will continue to cooperate with the authorities as they complete their investigations, and continue training and education efforts with facility staff," Dan Kramer, spokesman of Palm Valley Post Acute, said.

AZDHS releases detailed statement on Palm Valley's ‘delayed report’

ADHS takes all abuse allegations, including sexual abuse, seriously. On 11/17/23 the Department received a telephone complaint from a concerned staff member at Palm Valley Post Acute alleging that an employee accused of sexual abuse was still working at the facility. Our personnel rushed to the facility to investigate this serious allegation.

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. ADHS has an ongoing investigation into the facility’s delayed report.

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.

Despite the facility failing to respond to or appropriately report this situation in accordance with our statutes, our swift action in this investigation successfully ensured the alleged perpetrator was suspended and subsequently terminated to assure the safety of all other residents.

We are grateful to the complainant for coming forward with detailed information, and encourage others to make a report if you believe the health and safety of vulnerable adults may be compromised. As evidenced by this investigation, we make sure to address all complaints for the wellbeing of all Arizonans.

FOX 10 reached out to Palm Valley on Feb. 5 for a response to AZDHS's findings, and we have not yet heard back. On Feb. 9, however, we learned that Palm Valley has agreed to pay $2,000 in civil fines to AZDHS for four violations linked to delayed reporting of alleged sexual abuse of patient who became pregnant.

Victim issues statement via lawyer

On Feb. 19, we received a statement from a law firm representing the victim. The statement reads:

"'Jane Doe' was admitted to Palm Valley Post Acute on September 21, 2023, and immediately became a victim of Bobby Williams’ depravity.  What was at first unwanted touching and compliments soon turned into forcible rape.  These egregious acts of sexual violence continued for the entirety of her stay at Palm Valley.

Our firm helps survivors of sexual assault and human trafficking.  Ms. Doe is one such survivor, and we are committed to holding those liable for her life-altering injuries accountable to the fullest extent of the law.  We believe that this includes Palm Valley, as their egregious lack of care allowed Mr. Williams to prey on Ms. Doe without recourse.

Despite her calls for help—directly approaching the Administrator and the Director of Nursing while she was under their care—Palm Valley did nothing to stop the sexual violence from occurring."