DIAMONDVIEW 
I.D. 0038638
338 COUNTRY CLUB ROAD
CENTRALIA, ILLINOIS 62801
As a result of a survey conducted by representative(s) of the
Department, it has been determined the following violations occurred.  
                          "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.
These regulations are not met as evidenced by the following:
1.  On 3/4/99, E-3 provided the surveyors with the requested dates and
names of the clients involved in the Incident Reports reviewed. Per review
of the information submitted by the facility, R-8's name appeared numerous
times involving client on client abuse. 
R-1 is a 41-year-old ambulatory male that functions at a moderate level
and has diagnosis of CP.
Per record verification, R-1 is on a behavior program for aggression
defined as throwing and breaking objects. Per review, no program was
located that addressed R-1's physical aggression towards others. 
Per review of the facility's Incident Reports, the following incidents
were noted for R-1:
10/22/98: "R-2 was hit in the face, back and neck and legs. Hair was also
pulled out by a male resident (R-1).
                    
12/22/98: "R-1 stabbed female resident (R-7) in her right shoulder with a
fork during the breakfast meal."
Additionally, an Employee Incident Report was noted for the same day that
stated: When I (E-2) was breaking up a fight between a male (R-1) and a
female resident (R-2), "male resident (R-1) hit me real hard in the
stomach..." (E-2 was 7 months pregnant at the time of the incident.) 
Interview with E-1 revealed, R-1 was seen by the Psychiatrist on 10/2/98
and was placed on Depakote for aggressive behaviors. R-1 was to be seen
yearly or sooner if needed by the psychiatrist. 
Per review of the Incident Reports dated 10/22/98 and 12/22/98 and as
based on their severity, E-1 and E-3 confirmed that R-1 should have been
re-seen by the psychiatrist after these incidents. 
Based upon review, the facility has failed to modify R-1's behavior
program to address his severe aggression and has failed to have R-1
evaluated by a Psychiatrist as appropriate. 
Per review, the facility has failed to ensure that clients are not
subjected to physical abuse from R-1.
2.  Per record R-9 is a 25-year-old male that functions at a severe level.
Per review of R-8's Progress Note entries, R-8 has had more than 40
documented incidents of physical aggression from 3/98 to 3/99 towards
staff and clients of the facility. 
Per review of the Incident Reports and per review of the Progress Notes,
the following examples of client on client abuse by R-8 were noted.
3/27/98: Incident Report(s): "R-1 was hit by male resident (R-8)." "R-3
was hit by a male resident (R-8)." Progress Note: "R-8 was very angry at
another resident, (unsure of which resident) he hit one resident in the
back of the head. He hit another resident in the back and he hit a
scratched another resident in the arm. 
4/23/98: Incident Report: "R-9 stated that she was shoved off the bus.
Sent to the Emergency Room (ER)." Progress Note: "R-9 complained on pain
to right ankle. Stated she was pushed when getting off bus. Right ankle
slightly swollen..." "R-9 was taken to ER... R-9 stated that a male
resident (R-8) was in a hurry and wouldn't wait for her (R-9) to get off
the bus, then she (R-9) fell... Diagnosed with a sprained ankle..."
5/16/98: Incident Report(s): "R-1 hit by male resident (R-8)." "R-3
knocked down by male resident (R-8)." "R-5 hit and scratched by a male
resident (R-8)." Progress Note: (The surveyors noted five separate entries
for the date 5/16/98.) "R-8 hit one (R-5) resident on the back and
scratched him on the arm. He also hit a female resident (unidentified) and
pushed another resident down (R-3). During this time he also swung at
staff and was cussing and biting himself, asked him to go to his room and
he (R-8) refused but went outside." "R-8 ripped shirt sleeve of another
male resident (unknown)." "R-8 hit another male resident (R-1) on the
back. Do not know reasons for starting of these behaviors." "R-8 shoved
another resident on the concrete out back (unsure if this is R-3 or
another resident)."
6/20/98: Incident Report: "R-5 was scratched on both arms and hit in the
eye by another male resident." Progress Note: "R-8 hit and scratched
another male resident (R-5). He (R-8)left scratches and red marks on him
(R-5)... R-8 also hit the same resident (R-5) in the left eye. What
brought this incident on is not known."
7/27/98: Incident Report: "R-1 was hit by a male resident." Progress Note:
"R-8 was caught stealing food from the kitchen. When caught, he (R-8) hit
another resident (R-1) in the back... He (R-8) proceeded to hit,  scratch
and spit on staff..."
8/27/98: Incident Report: "R-5 hit on shoulder by another male resident
(R-8)." Progress Note: "For unknown reasons R-8 hit another male resident
(R-5) on the shoulder. He (R-8) also called other residents names. He
(R-8) also bit himself. After awhile he calmed down." 
9/12/98: Incident Report: "Male resident hit R-9 in the back and pulled
her (R-9's)hair."
 
Progress Note: "R-8 had behaviors all day today. He really got out of hand
bad. He was spitting, hitting and cussing at all of the staff. He hit a
female resident (R-9) really hard in the back several times and was
pulling other resident's hair."
                    
10/7/98: Incident Report: "R-5 was hit on the back 3 to 4 times by a male
resident (R-8)and was scratched on the face." Progress Note: "R-8 had a
temper tantrum for no apparent reason. He (R-8) hit and scratched one male
resident (R-5). He (R-8) hit one female (R-9)... He (R-8) also spit at
several residents..."
11/21/98: Incident Report: "R-5's face was scratched by another male
resident." Progress Note: "For no apparent reason R-8 scratched another
resident (R-5) (in the face). He (R-8) also pulled his hair.
1/22/99: Incident Report: "R-2 was hit in the arm by a male resident."
Progress Note: "Tonight a female resident (R-2) yelled for me to make R-8
stop touching her breast. When I told R-8 this is inappropriate and to
stop, he (R-8) hit the female resident (R-2) and me.  R-2 then tried to
scratch and hit another male resident..."(the other male client was not
identified by the facility). 
2/16/99: Incident Report: "R-2 was hit by another male resident (R-8)."
Progress Note: "R-8 hit another female resident (R-2) in the left eye this
evening." (R-2 sustained a black eye.)
R-8's behavior program, R-8 is program to reduce incidents of physical
aggression defined as hitting, scratching, spitting on others and
inappropriate sexual behavior. Per review of the methodology, staff are to 
provide R-8 with two prompts to stop the behavior, if R-8 does not stop,
he should be then asked to remove himself to another area. No other
methods are identified in the program plan for staff if R-8 does not
comply and does not remove himself from the area. R-8 is to be praised for
complying after 2 verbal prompts and is to be provided with 1 on 1
conversation with staff. If R-8 stops his behavior after 2 verbal prompts,
staff are not to count the aggressive behavior as an incident. 
R-8's behavior program was revised on 1/12/99, however, per review of the 
behavior program no revisions were made in the program methodology. The
only revision made on R-8's behavior program was that R-8 was advanced to
step 5 of the behavior program to have no more that 0 incidents of
aggression for 6 consecutive weeks
3.  Clients are subjected to client on client sexual and/or psychological
abuse. R-8 is a 25 year old male that functions at a severe level of
mental retardation. R-8 was observed in the facility on 3/4/99 form 7 a.m.
to 8:03 a.m.
R-8 was observed to be following R-9 and R-9's reaction to his behavior
was to yell at R-8 to "Stop" "Leave me alone". R-8 continued following R-9
and R-9 continued to tell him to stop for the next fifteen minute period.
E-1 finally told R-8 "Leave her (R-9) alone please" "Why don't you guys go
find something to do?". No other intervention was done by staff at that
time. 
At 7:25 a.m. R-8 was standing in the hall beside R-9 and R-9 was saying to
R-8 "Stop following me." "Leave me alone." E-1 intervened and told R-9 to
go to her room and make her bed. R-9 complied and E-1 closed the door to
the female wing to prevent R-8 from entering. E-1 again asked R-8 to "find
something else to do". R-8 refused to leave the female wing's doorway and
then E-1 physically blocked the door to prevent R-8 from entering. R-8 was
observed to take E-1's hand and was squeezing it with enough force that
E-1 said " stop digging your nails into my hand and go back into the
living room" in a very firm voice. R-8 did release E-1's hand but only
walked a few feet away from the doorway and stood until R-9 came from her
room and walked into the living room. R-9 sat  down on the couch with 3
other clients. R-8 followed her into the living room and paced the floor
until 7:42 a.m.. when another client got up off the couch, R-8 went
directly to the couch and sat down beside R-9. E-1 observed this action
and asked R-9 if she wanted to move to the small couch beside R-4. R-9
said yes and moved to the small couch. R-8 was visibly agitated because
R-9 moved and there was no room for him beside her. At 7:55 a.m. E-1 was
out of the room to assist another client and R-8 walked to the small couch
and tapped R-4 on the shoulder, indicating by body language that he wanted
him to move. R-4 appeared to understand what R-8 wanted and was attempting
to get up off the couch so R-8 could take his place beside R-9, but staff
re-entered the room and prevented R-8 from sitting beside R-9. E-1 said to
R-8 "leave her alone, go find something else to do". R-8 continued to
stand in front of R-9 until the bus arrived at 8:03 a.m. and clients left
for the day training site. Per interview E-1 verified that R-8 "was
becoming more aggressive in his behavior toward R-9, and R-9 did not want
his attention. 
E-1 also verified that there was no structured activity in the morning to
keep the clients occupied. E-1 stated "one person can only do so much."
"the other staff person is new, so I do what I can." 
Per record verification, in the past year R-8 has had at least 14 charted
incidents of inappropriate sexual behavior towards female clients of the
facility. 
Per review of the documentation found in R-8's Progress Notes, R-8 targets
female clients of the facility.  The names of the female clients were not
consistently identified in the entries and most of the entries did not
correspond to the Incident Report Incidents. Charted examples of this type
behavior are as follows: 
3-28-98 "While using the restroom at Forbe's Lake, R-8 stood by the
women's bathroom door looking in every time the door opened, when asked to
move away, he got mad and sat down on the ground...." 
4/1/98 (Dated as Late entry for 3/27/98) "R-8 was arguing with two other
resident. He (R-8) was wanting to go down to the women's wing and one of
the female residents was telling him not to. He (R-8) then started hitting
people..."
On 5-2-98 "When asked to go to another area of the building because he
(R-8) was on the women's end and a resident was bathing, he (R-8) got
upset and started biting himself then he hit staff and knocked another
resident down..."
"On 5-3-98 "I (staff ) went down to the ladies bathroom to check on one of
the female residents and I walked in on R-8 putting his hands all over her
body. I (staff) told R-8 to leave and he started spitting at me and
shaking his fist." 
On 5-5-98 "I (staff) went to check on one of the female resident to see
had she gotten into bed, I (staff) found (R-8) in a female resident's room
and she was half dressed getting ready for bed and another female resident
was putting on her clothes in the shower room.
On 5-20-98 "Tonight I (staff) walked outside and observed R-8 unbuckling
a female resident from Park Place. He (R-8) proceeded to put his hands on
her stomach. I (staff) quickly buckled her back up and she went home to
Park Place."
On 5-23-98 R-8 trying to fondle R-2's private areas.
7-11-98 R-8 was noticed to be following an unidentified female.  The
female client told R-8 to leave her alone and R-8 hit her.
On 7-16-98 R-8's record indicates he was "bothering two female clients"
and became aggressive to staff when asked to stop, hitting and scratching.
10/7/98 "R-8 was down on the women's wing, when asked by staff to leave,
he hit one staff member then spit in the face of another staff."
On 1-8-99: "R-8 grabbed a female resident's breast several times tonight,
when asked to stop he clawed a staff member on the arm. Later in the
evening, R-8 was caught trying to spy on another female resident while she
was in the bathroom.. When asked to go to his room for a while, he spit on
a staff member."
On 1-22-99 "Tonight a female resident (R-2) yelled for me to make R-8 stop
touching her breast. When I told R-8 that this is inappropriate and to
stop, he hit the female resident (R-2)..." 
2-19-99 "R-8 was touching a female resident's breast..."
An undated entry in R-8's progress notes states R-8 was found in bed with
R-6.  He (R-8) was putting his hands in the groin area of R-6.  I (staff)
told R-8 to stay out of her room...
R-8's behavior program is to reduce incidents of physical aggression
defined as inappropriate sexual behavior, hitting, scratching, and
spitting on others.
Per review of Per review of the methodology, staff are to provide R-8 with
two prompts to stop the behavior, if R-8 does not stop, he should be then
asked to remove himself to another area. No other methods are identified
in the program plan for staff if R-8 does not comply and does not remove
himself from the area. R-8 is to be praised for complying after 2 verbal
prompts and is to be provided with 1 on 1 conversation with staff. If R-8
stops his behavior after 2 verbal prompts, staff are not to count the
sexual behavior as an incident.
R-8's behavior program was revised on 1/12/99, however, per review of the
behavior program no revisions were made in the program methodology. The
only revision made on R-8's behavior program was that R-8 was advanced to
step 5 of the behavior program to have no more that 0 incidents of
aggression. Additionally, per record verification and as confirmed through
interview with E-3, no methods have been added to R-8's behavior program
to train more appropriate sexual expressive behaviors.
Per interview with E-3, R-8 was seen by the psychologist in October 1998
and shown some videos on appropriate sexual expression. (No documentation
was available for that session.) Additionally, the psychologist
recommended that the facility implement a plan to shut the women's wing
door when female clients are bathing or are on the wing, however, as
observed on 3/4/99, R-8 continues to go down on the women's wing and
becomes aggressive when his access is denied.
As based upon review, the facility has failed to revise R-8's behavior
program as needed and has failed to have R-8 evaluated as appropriate to
determine the most suitable therapy to address his sexual behavior. 
Per review, the facility has failed to ensure that clients of the facility
are not subjected to sexual and psychological abuse. 
A Serious and Immediate Threat was called on 3/5/99 at 1:45 p.m. 
Core Statement: Failure to uphold patient rights whereby violations can
result in harm or injury. 
5. Failure to protect patients from bodily harm or trauma. 
The Serious and Immediate Threat was removed on 3/5/99 at 3:30 p.m. when
R-8 was placed on 1:1 by the facility and scheduled to be seen by the
psychiatrist on 3/8/99 for evaluation.