CARLINVILLE ESTATES I.D. Number 0039362 1221 SOUTH PLUM STREET CARLINVILLE, ILLINOIS 62626 "A" VIOLATION(S) An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. Resident as perpetrator of abuse. When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that another resident of the long-term care facility is the perpetrator of the abuse, that resident's condition shall be immediately evaluated to determine the most suitable therapy and placement for the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility. R 8 as well as other clients (often not identified) in the facility were victims of numerous incidents of physical, verbal, sexual and psychological abuse by R 2. R 2 is a 48 year old male with a diagnosis of Severe Mental Retardation, CP - Infantile, Anxiety Disorder and Hemorrhoids who was admitted to the facility on 1/7/91. Per R 2's behavior plan, R 2 has identified maladaptive behaviors of physical aggression, verbal aggression, teasing, pestering, bossing others, and inappropriate touching. Per a psychotropic medication review, R 2 "teases and bosses daily at least and hits others at least once a week, sometimes more". A social history presented at his 12/97 IPP states R 2 "has difficulty controlling his teasing and bothering the other residents...he threatens to tear up their things and to hit or kick them." Verified by review of incident reports, universal notes, behavior documentation, and staff interview, R 2 has demonstrated, toward staff as well as clients, numerous incidents of physical aggression, verbal aggression, fights with other residents, inappropriate touching, property destruction, teasing, disregarding privacy when clients are in the shower and bossing of others. Per the direct care staff, R 2 chose opportunities to display maladaptive behavior when staff were busy or not available - such as on van rides, at medication pass time, when staff were assisting with showers, preparing meals, or when clients were unattended outside, in the activity room, bedrooms, kitchen or when out of sight. E 2 stated R 2 only targeted R 8 for aggression. R 8 is a 34 year old male with the diagnosis of Moderate Mental Retardation, Unspecified Affective Psychosis who was admitted to the facility on 9/30/98 from Jacksonville Developmental Center. R 8 was the target of abuse from R 2 from shortly after his admission to the facility. Evidence from staff and documentation reviewed, since 9/98 R 2's aggression toward other clients included many clients at the facility prior to R 8's admission: Example follow: • 9/2/98 R2 hit, kicked and bit a male peer (breaking the skin) and stepped on his heel. • 9/16/98 R 2 pinched peers, fractured finger (resulting in peer cursing and yelling). • 9/17/98 R 2 hit peer in the back and neck. • 9/18/98 R 2 pulled female peer from the couch so he could lay down. • 9/19/98 to 9/22/98 altercations with peers included fights and inappropriate touching. • 9/23/98 R 2 had a physical fight with a peer then hit him with a hanger. • 9/28/98 R 2 hit R 3. After "staff was able to hold him back " tackled R 3 (who wears lower leg braces) to the floor and bit skin from his head resulting in bleeding from the wound. • 10/3/98 pulled peer from a couch so he could sit down. In addition, an incident was documented on 10/4/98 and 10/12/98 of spraying Lysol at clients and hitting staff. Police were called to the facility on 10/4/98 due to R 2's escalated behavior. Per interview with R 8, he was the target of R 2's physical, sexual and psychological abuse from the time of R 8's admission. R 8 expressed fear to live at the facility and while crying, stated he wanted to move. R 8 said he would tell the staff, but nothing was done. "R 2 would tease me, call me names, put up his finger middle) at me - if I walked away, he would follow me. He went outside... then bangs on my window and looked in my window and made faces at me." R 8 stated he had been spit on, punched in the face, nose, bitten on the chest, face, sprayed with water, was made fun of by R2, was pushed and taunted. R 8 stated R 2 also touches his buttocks. R 8 stated he would go into his room and barricade his room by placing a chair against the door to protect himself. This was verified by E 13 who stated most weekends R8 would block his room door with a chair to keep R 2 out of it and to protect himself. E 13 stated R 8's room is next to R 2's room and incidents would start first thing in the morning and continue through the day - 2 to 3 per shift. An incident report dated 11/7/98 (Saturday at 4:45 pm) stated "R 8 was in his room with door shut with a chair blocking the door. R 2 tried to break in and steal R 8's hat. R 2 got me to open the door to see what was going on. R 2, then ran past me and I held him back, then he spit in R 8's face and knocked me back then continued to fight until I pulled them apart with the help of (another staff)". E 12 also witnessed R 2 throwing R 9 (a very small stature female) onto R 8 several times on 10/18/98 and R 2 throwing and breaking R 8's television on 11/8/98. E 1 stated he was not aware the television was broken from the incident and had not replaced it as of 11/17/98. Verified by E 5, E 6, E 7, E 8, E 9, E 10, E 11, E 12 and E 13, R 8 has been the target of R 2's aggression and R 8 is afraid of R 2. The facility failed to protect R 8 and other clients from R 2's aggression following the incidents that increased in intensity and frequency. Recorded incidents regarding R 8 include: • 10/6/98 and 10/10/98 R 8 reported other resident (identified as R 2 by R 8) touched him "where he shouldn't". Reported to staff. • 10/17/98 at 8:25 AM while sitting outside R 8 came running in the facility bleeding - stating he was bitten on nipple, choked and hit in mouth by R 2 after R 2 patted R 8's "butt". Incident resulted in bleeding from both sides of his nose, middle upper lip and right side of chest from bite. The police were called to the facility with the approval of E 1. Verified by Z 8 the police were called. Recommendation was made by police to call Mental Health. Per Z 8, the facility director stated it would be taken care of "in house". Per record notes, R 8 was upset most of the evening and complained of pain in the chest area where bitten. Steps were not taken to protect R 8 from further injury / abuse. • 10/18/98 Per record notes in R 2's chart and verified by E 12, R 2 threw another resident (identified as R 9 by E 12) at R 8 several times. On the same day R 2 sprayed water on R 8" making him throw up and laughed about it". Steps were not taken to protect R 8 or R 9 from further injury / abuse. • 10/19/98 R 2 walked in the bathroom while R 8 was taking a shower and allegedly kicked R 8's right leg. "No serious injuries recorded" Record notes state R 8 was in a "melancholy mood" that evening. Steps were not taken to protect R 8 from further injury / abuse. • 10/23/98 Per R 2's record, R 2 poked another resident very hard and has been walking in on other residents while they are taking a shower. On a van ride R 2 was told to keep his hands to himself numerous times, would not stop teasing. At least every 10 minutes for 2 1/2 hours had to be told to leave clients alone. {"would not le