FONDULAC WOODS HEALTH CARE CENTER
Facility I.D. Number 0043554
901 Illini Drive
East Peoria, IL 61611
Date of Survey 3/8/00
Complaint Investigations 0020708, 0020902, 0020825, 0020906, 0021252
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
This REQUIREMENT is not met as evidenced by:
Based upon record reviews, interviews, and observation, facility had a male employee who was found in the act of sexually molesting one female resident and who admitted to fondling another female resident. Facility staff was aware of employee's inappropriate behavior with female residents in the past before this incident occurred.
Z1 was interviewed on 3/7/00 at 8:16 a.m. Z1 stated that she was assigned to care for half of the hall that R1 lived on. This was for the evening shift of 2/22/00. Z1 went to do rounds on the residents in her care around 9:15-9:30 p.m. As Z1 went down the hall, Z1 noticed that the door of R1's room was shut. Z1 found this peculiar because Z1 recalled leaving it open after being in the room to care for the residents. Z1 went to the door and opened it. Z1 saw one side rail of the bed down. Z1 saw E1 lying in the bed on top of R1 with E1's face turned toward the window in the room and away from the door. Z1 could not see what E1 was doing while in the bed with R1. E1 turned when the door opened. Z1 immediately backed out of the room. E1 called to Z1 to wait. Z1 stated no and told E1 that he needed to leave the room and come talk to the nurse.
Per Interview of E2, it was determined that on the evening shift of 2/22/00 E1 was found in bed with and on top of R1.
Z1 and E1 were both assigned to care for the residents of B wing. Z1 was to care for one side of the hall while E1 cared for the other. R1 was not on the assigned side of hall that E1 was working.
Per documentation in nurses notes of R1's record. Z1 walked to the nursing station with E1 following behind Z1 at 9:15 p.m.
At the nurses station was E2, Z1 began telling E2 that Z1 could not work here anymore. Then E1 came to the nurses station and said, "I did a no no." Z1 then stated ask him (E1) what happened.
Per E2, E1 told that R1 "was making advances at me and I did a no no, I did a no no."
Per E2, E2 then talked with Z1. Z1 stated that Z1 went into the room of R1 after opening the closed door and found E1 on top of R1.
When E2 was examining R1 at 9:45 p.m., E2 asked R1 if anyone did anything to her. R1 replied "he just rubbed and kissed me."
Information taken from the nurses notes was written by E2. Confirmed in interview with E2 at facility on 2/25/00.
E2 also stated in interview that E2 had talked with E1 before this incident about how E1 touched the female residents of the facility. E2 stated that E1 would pull female residents down in his lap to hold them. This was seen on more than one occasion with R3.
E2 stated that this behavior had been reported to Z2. It was E2's understanding that E1 "had been written up for this."
Personnel file of E1 contained no such documentation in regards to this instance or any of the other times that inappropriate behavior was noticed by co-workers. No forms provided for completion per facility policy were observed completed.
E2 sent E1 out of the facility at approximately 9:30 p.m. and notified the local police department, family of R1, and facility administration. Illinois Department of Public Health Regional Office was notified by the facility on 2/23/00 at 8:45 a.m.
During interview, E4 was asked the type of investigation that was done following the 2/22/00 incident. No written investigation was done as facility policy allows for. No available forms per the policy were completed. E4 did state that E4 had E3 interview the other alert female residents that were housed on the same wing as R1.
There was no indication as per policy that the suspected employee's personnel file was reviewed.
Accident/Incident Report filled out by E2 and E6 addresses only what happened. It contains no investigation into the incident.
R1 was sent to the hospital emergency room at 12:30 p.m. on 2/22/00. No bruises or marks were observed. A sexual assault evidence collection kit was obtained.
Per interview with Z3 on 2/25/00, it was revealed that E1 had admitted to Z3 that E1 had kissed R1 and squeezed the breasts of R1 and also R2. E1 had been arrested and charged with two counts of aggravated criminal sexual assault.
Minimum Data Set (MDS) dated 12/14/99 was reviewed. MDS indicates that cognitive level of R1 is modified independently. R1 has periods of altered perception of awareness of surrounding. The mental function of R1 per MDS varies over the course of the day. MDS indicated that R1 usually understands the spoken word.
Observation and interview of R1 was done by surveyor of 2/25/00 at 2:45 p.m. Per record review, R1 is a 93 year old female weighing under 100 pounds.
R1 refused to discuss E1 with the surveyor. R1 admitted that there were a few "boys" that worked in the facility. R1 felt that the "boys" were "the nurses sons." R1 did state when asked that she had been to the hospital just a few days ago but would not discuss why. R1 stated that R1 did not want to "gossip." R1 then began to talk of topics unrelated to the conversation and was confused as to who surveyor was or what had just been discussed. When spoken with in the late afternoon of 3/7/00, R1 was disoriented and looking for her car to take an employee home. R1 then voiced that she needed to get them both to church.
It was the surveyor's determination after speaking with R1 that she would not be able to make a logical judgement as to whether or not she wanted E1 to do what E1 did to her on the evening of 2/22/00.
R2 was present in the room when surveyor spoke with R1. When conversation was made with R2, no intelligible response could be heard. R2 made noises only and no words could be deciphered. R2 is a resident who is totally dependent upon staff of facility for all activities of daily living. R2 is noted as being moderately impaired on a cognitive level and incapable of making her own decisions.
Z4 was assigned to work the second shift on the evening of 2/22/00. Z4 was interviewed on 3/6/00 at 4:55 p.m. Z4 stated recollection of being present at the nurses station when Z1 came to it and stated that Z1 had just found E1 in the room of R1 in the bed of R1 and on top of R1.
Interview was held with E3 on 2/25/00 at 1:40 p.m. E3 stated E3 was present when R1 was interviewed by the police officers. E3 stated that R1 kept repeating "I didn't do anything wrong." E3 stated that R1 was reluctant to talk with the police and stated that R1 said "I don't want to gossip." E3 stated that since the incident of 2/22/00, R1 seems to be very untrusting and was not that way before.
E10 was interviewed on 3/7/00. Facility staff schedule indicates that E10 frequently works the second shift as did E1. E10 stated that E1 was frequently observed by other staff of the facility pulling the females down between his legs to sit on his lap. When asked if E10 felt that this was inappropriate behavior. E10 stated that E10 would certainly not want that done to someone that was caring for E10's mother. When asked if supervisory staff of the facility were aware of this behavior, E10 stated that the nurses had "warned him about it many times and told him to stop."