CASTLEHAVEN CARE CENTER
I.D. Number 0042515
225 CASTELLANO DRIVE
SWANSEA, ILLINOIS 62226
Survey Date: 7/2/99
The facility shall notify the resident’s physician of any accident, injury, or significant change in a resident’s condition that threatens the health safety or welfare of a resident. An owner, licensee, Administrator, employee or agent of a facility shall not abuse a resident.
A facility employee or agent who becomes aware of abuse of a resident shall immediately report the matter to the facility Administrator.
EMPLOYEE AS PERPETRATOR OF ABUSE. When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that an employee of a long-term care facility is the perpetrator of the abuse, that employee shall immediately be barred from any further contact with residents of the facility, pending the outcome of any further investigation, prosecution or disciplinary action against the employee.
These requirements are not met as evidenced by:
Based on record review and staff interviews, the facility failed to take appropriate action to prevent abuse of one resident in the sample when E8 physically abused R1 in multiple instances on 5/30/99 and E5 verbally abused R1 on 5/30/99.
The facility staff who witnessed the abuse of R1 failed to intervene and failed to immediately report the abuse, and the facility failed to thoroughly investigate the reported abuse that occurred on 5/30/99.
Findings include:
1. The physical abuse took place on 5/30/99 and was not reported to the Administrator until 5/31/99. Interview of E1 revealed she began an investigation on 5/31/99 and obtained written statements. E8 was suspended on 6/1/99 pending the facility investigation which resulted in E8 being terminated on 6/3/99.
2. E1 stated the facility staff did not investigate E8's statement about E5's verbal abuse and she was not aware that E9 and E10 also witnessed abuse on 5/30/99.
E1 stated they did not identify that R1 had been abused two times by E8 and verbally abused by E5 on 5/30/99. E1 stated that with the additional information given by the surveyor she reopened the investigation on 6/9/99. E5 was suspended on 6/9/99 and on 6/11/99 E5 was terminated.
3. Record review and interview of E11 revealed R1 was observed on 5/31/99 at 8a.m. to have a contusion to the right side of the face approximately 3 x 5 scattered bruises. Small bruises x 2 (0.5 and 1 cm diameter) to forehead. Scratches noted to right side of nose approximately 1 cm in length etiology unknown. Incident reported to the Administrator for investigation about 9:30a.m. according to E11. E11 stated when she asked R1 what happened he said, "I think I got the worse end of it." E11 described the injuries as a big scratch on the side of his nose and the side of his face had little tiny broken blood vessels along with 2 bruises. E11 stated when she left duty on 5/30/99 at 8:30p.m. R1 did not have any injuries. E11 worked from 7a.m. to 8:30pm and described R1 as being calm all day, no excessive pacing.
E11 stated E8 had made a comment when he came on duty on 5/30/99, 3-11 shift. He stated why are they sticking me on this same hall. E11 responded to his statement by saying don't even come down here with an attitude. E11 stated she did not report E8's attitude to anyone. E11 stated on 5/31/99 that she was called by E12 to talk to E5. E5 stated he had seen E8 hit R1 on 5/30/99. E5 said he was sick all night and could not sleep. E11 said after she completed the med pass around 9:30a.m. she took E5 to E1 so he could relate the incident. E11 said E12 came in at the same time.
4. Interview of E5 revealed on 5/30/99 in the evening, he witnessed R1 attempting to go outside following E9 and E10 leaving for their break. E8 told R1 to sit down. R1 refused to comply, and E8 slapped R1 with his open hand on the left cheek. E5 stated you could hear the slap and R1's head jerked back from the hit. Then E8 slapped him again. R1 was very upset. E5 stated E8 hit R1 again, "he literally beat him up." E8 had a soup bowl and hit R1 on top of the head 2 or 3 times. E8 pushed R1 violently into a room across from the nurses station and closed the door on R1. E5 also stated he thought E8 hit him in the chest. E5 stated R1 did not raise his hand to defend himself and he did not make a sound. E5 stated E8 laughed about it and said he was going to tell the nurse only that he pushed him in a room. E5 stated he did not report to anyone about what he witnessed until the morning of 5/31/99. E5 stated E12 was on the 200 hall at the time the incident occurred on the 100 hall. E5 stated E8 was frustrated that evening. He stated he didn't want to work on the 100 hall and was assigned to work a double on that hall on 5/30/99.
In addition, E6, E9 and E10 witnessed an incident on 5/30/99 in the evening that occurred after E9 and E10 came back from break.
a. E6 stated he witnessed E8 throw a ball at R1 hitting R1 on the arm. R1 tried to hit E8, and
E8 hit R1 in the face 3 times. R1 fell against the corner of the wall and onto the floor with E8 on top of him. E8 had his knees and legs in R1's chest and stomach. R1 sustained a scratch on his nose that was bleeding down his face. R1 was helped up and the blood was wiped from the scratch on the nose. E6 did not intervene. He stated he was "kinda dumfounded, and it was time for him to leave."
E6 stated I just left off the hall and did not report to anybody. E6 stated "the way I see it, I'm not the boss. I wanted to avoid the whole situation." E6 stated he told E12 when she got home from work.
b. E9 stated on 5/30/99 in the evening, when coming back from break R1 and E8 were into it. R1 started after E8 and hit E8. E8 then hit R1 again at least 3-4 or 4-5 times. R1's face was very red and stayed that way when staff left the facility at 11p.m.
E9 stated she saw E8 hit R1 with a closed fist and they exchanged words. R1 was walking around and came back a little later stating "you thought I forgot." E8 tried to grab R1 and they ended on the floor. E8 was on top of R1 and they wrestled. E8 held R1's arms down. He had his hands around R1's wrists. R1 could not move. E9 stated she sent E6 to get E12, as there wasn't a nurse on the 100 hall, but she did not come right away. When she did come she said it looked like R1 got hit too. E9 stated she did not report what she saw and she did not try to stop the abuse.
c. E10 stated on 5/30/99 in the evening after coming back from break E8 threw a ball and hit
R1 on the arm. E8 hit R1 2 to 3 times by smacking his jaws using both hands. E8 and R1 were on the floor rolling around and E8 restrained R1's hands. E10 stated she did not intervene, she just stood back and watched. She said she could not do anything with 2 men fighting on the floor. E10 said when E12 came to 100 hall, E8 told her R1 needed a shot, that he was on a rampage. E10 said when they give him a shot R1 is quiet the rest of the night. E10 said E12 said R1 looks like he was hit and E8 said "yea, I hit him, I sho hit him. I'm not going to lie, I hit him."
6. After the above incidents on the same evening E6, E9 and E10 also witnessed verbal abuse to R1.
a. Interview of E6 revealed E5 was cursing saying to R1, "that's why you got your ass kicked because you're fucking with the wrong crew."
b. Interview of E9 revealed E5 said to R1 that R1 "was a tough mother fucker." E9 said R1 would hit E5 and jump at him like they were going to fight. E9 did not report this or take action to stop the abuse.
c. Interview of E10 revealed E5 was messing with R1 and said, "This white boy thinks he's tough. I'll kick his ass. This mother fucker thinks he's bad. I'm going to kick his ass." E10
did not stop the abuse or report it.
7. Interview of E8 revealed, "it wasn't me. It was a housekeeper." E8 stated he did not hit R1, but he did have a tussle with R1. R1 had a bowl and E8 stated he did put his hands on R1's shoulders, trying to get the bowl away from him. We both fell down. E8's written statement to the facility identified E5 hit R1 and talked rough to residents. E8 stated he saw E5 hit the man because R1 walked on across the wet floor.
8. E12 stated on 5/30/99, E8 came to her and he asked not to be put on 100 hall for 2 weeks, just 2 weeks and they scheduled me anyway. E8 asked her for a paper to write a resignation. E12 said to E8 did you tell E13 and he said they said they could not find anyone to work down there. E12 did not take action on E8's statement. E12 stated she was working on the 200 hall on 5/30/99 and E11 was working over from the day shift on 100 hall. She stated about 9:30p.m. or 10p.m., E5 came to her and asked if anyone had a contagious disease on 100 hall. E5 said R1 scratched him when he tried to redirect him. E12 said come get me if there's any more emergency, if R1 gets worse combative. E12 told E5 she would be down there after she finished her meds. E12 said she did go to the 100 hall after she passed the 9:00p.m. meds. E8 told her to give R1 a shot. E12 stated she took R1 with her and as they passed E5, R1 said he hit me and pointed to E5. E12 said she asked E5 if he hit R1 and he said no. E12 said she did not see any injury so she did not investigate further.
E12 said no one reported anything else until she got home after work. E6 told her what happened. The next day, 5/31/99, she came on duty. About 8a.m., E5 told her "(E8) beat the shit out of (R1)." E12 said she did not report what E6 and E5 told her until she passed her medications on the 200 hall at about 11:00a.m. on 5/31/99. E12 said when R1 becomes combative, she tells the staff to come get her. She stated R1 will calm down with a soft voice, someone to listen to what he thinks is wrong, or just take him for a walk.
9. Interview of Z1 revealed she had been contacted regarding injuries of unknown origin observed on 5/31/99 at 8a.m. She stated the nurse described the injuries but no one had reported that the injuries were from abuse. Z1 stated that from the description of the incident from the above witnesses and review of the resident record with the surveyor, R1 could have sustained a re-break of the 10th rib that occurred on 4/29/99.
R1 could have fractured other ribs due to the ribs being diffusely osteopenic. R1 developed cellulitis
of the elbow on 6/1/99 and the possibility of trauma during the incident could have caused it. R1 could have a slow bleed from the prolonged clotting time (6/1/99 pt 14 sec/control 12 sec). R1 was on Coumadin 3 mg a day at the time of the incident. R1 could have suffered from blunt trauma to the abdomen, rupture a spleen or liver. R1 could have had his heart stopped and died.
Z1 stated she did not get an update of the alleged confrontation. She stated R1 is usually a calm man, and it takes something to trigger aggressiveness behavior. She said this is terrible. He doesn't deserve this. No one deserves to be treated like this. Z1 said had she been notified she would have ordered neuro checks, possibly rib x-rays, and monitoring for symptoms of the above possible injuries.
10. Interview of Z2 who is treating R1, for what he described as severe sustained long term combativeness, stated he did not recall being notified of abuse to R1. He felt due to lack of R1's memory recall ability most probably R1 would not have suffered long term effects from the above incident. He stated the recent increased agitation of R1 could be because of staff treatment of R1. He stated R1 had a history of severe, long term combativeness and is capable of inflicting harm.
11. R1's record review revealed R1 was admitted to the facility on 2/1/99 and R1's date of birth is 5/20/27. R1 has diagnosis of Psychosis Axix III, HTN, CAD.