IONA GLOS SPECIALIZED LIVING CENTER
Facility I..D. Number : 0022996
50 S. Fairbank St.
Addison, IL 60101
Survey Date: 8/30/00 Annual Licensure
The facility shall notify the Department of any incident or accident which has, or is likely to have a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department.
The facility shall also immediately notify the resident's family, guardian, representative, conservator and any private or public agency financially responsible for the resident's care whenever unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
A FACILITY ADMINISTRATOR WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER BY TELEPHONE AND IN WRITING TO THE RESIDENT'S REPRESENTATIVE. (Section 3-610 of the Act)
A FACILITY ADMINISTRATOR, EMPLOYEE, OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL ALSO REPORT THE MATTER TO THE DEPARTMENT. (Section 3-610 of the Act)
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 (Section 3-612 of the Act)
These Regulations are not met.
I. R12 is a 52-year-old ambulatory male diagnosed as severely mentally retarded. In addition, he is diagnosed with hypothyroidism, gastritis, seizure disorder, cerebral palsy, ataxia, tardive dyskinesia, mood disorder, and dementia with agitated behavior (per his 9/07/99 Individual Support Plan-ISP). This ISP notes that R12 "does present a history of sexual advancement towards others."
1) Per review of facility incident reports on 8/15/00, a report indicates that on 2/20/00 at 11a.m., E4 found R12 "on top of R16 with their pants down." When interviewed on 8/15/00 at 4:50 p.m., E4 stated that this incident occurred on the bathroom floor between the two residents' rooms (in Home 2). E4 went on to say that it appeared as though R16 (profoundly mentally retarded with Down's Syndrome and non-verbal) "was just off the toilet; his outer pants and underwear were pulled down." E4 said he thinks R12's pants were also down. E4 stated that R12 "is known for this type of behavior; he can be the aggressor." E4 also said that these two residents were probably unsupervised for about 10 minutes. Per documentation by E5 on the 2/20/00 incident report, R16 "was alone for no more than 5-7 minutes." E5 joined us during the interview (with E4) on 8/15/00 and stated he understood there was a recent incident involving R12 at Eldridge Day Training (DT).
On 8/16/00, two incident reports involving R12 were reviewed at Eldridge DT.
2) One incident report was dated 8/02/00 11 a.m. This report read that R12 was found "on top of R14 pulling his pants off in the doorway of the bathroom." R14 is profoundly mentally retarded and non-verbal.
An 8/2/00 11am incident of sexual abuse at Eldridge DT was not reported to E26 and E1 until the next day (8/3/00). In the interim, a second sexual exploitation by R12 occurred on 8/3/00.
3) The second report was dated 8/03/00 12:50 p.m. This report read that E9 walked into the bathroom "and found R12 on R15 and R15 didn't have anything on from his waist down." R15 is blind.
Per interview with E9 on 8/16/00 at 11:45 a.m., when she came upon R12 and R15 on 8/03/00, R12's pants were unzipped and R15 was naked from the waist down. E9 went on to say that R15 "looked like he had been wrestling and possibly crying; his face was red." E9 stated she didn't "know how long they (R12 and R15) were in there."
4) On 8/17/00, DT provided a copy of an incident report of 12/17/99. According to the report, at 9:40 a.m. on 12/17/99, R12 "was found in the restroom with another individual. She (Z1) was on the floor and R12 was standing over her with his pants down holding his penis." Per E1 on 8/22/00, Z1 involved in this incident is not a resident of this facility.
On the incident report of 2/20/00, a notation by E2 reads that there will be a "referral for sexuality assessment and change in protective supervision" for R12. On interview with E5 on 8/16/00 at 2:50 p.m., he stated that "everybody in the house (where R12 resides) is on the same level of protective supervision." On 8/16/00 at 3:22 p.m., E2 was interviewed and revealed that a sexuality assessment was completed on R12 following the 02/20/00 incident; however, she was unsure if a change had been made regarding his level of protective supervision. E13, interviewed on 8/17/00 at 11:17 a.m., stated R12 has "no specific monitoring plan, same as everyone else" in Home 2. E13 stated, "no one in Home 2 has monitoring for any special reason." E13 was asked if she was aware of any clients involved in any sexual activity or incidents, specifically R12. E13 stated she was not aware of R12 being involved in any sexual activity. E13 verified she was not aware of an incident from February 2000 involving R12 and R16. No documentation regarding a change in protective supervision was noted in R12's file.
Per interview with E8 on 8/16/00 at 12:15 p.m., as of 8/04/00, R12 is not to be left unsupervised by staff at any time while at DT.
Per file verification, R12 is on a behavior plan which does not include sexual advancement.
R12's IPP notes he has a "history of sexual advancement towards others", had an incident of such behavior at DT on 12/17/99 and another such incident at the facility on 2/20/00 after which R12 was to have had a change in his protective supervision, but did not. Two more incidents of sexual aggression occurred at DT on 8/02/00 and 8/03/00. E5 stated during an interview on 8/16/00 at 2:50 p.m., that no special staffing has been held to address R12's sexual behavior.
Following the 2/20/00 incident between R12 and R16, no change in protective supervision for R12 occurred at DT until 8/4/00. No change in supervision transpired at the facility residence until after meeting with E2 on 8/16/00 at 3:22 p.m. At that time on 8/16/00, E2 said that R12 would now be on 10 minute checks while awake. On 8/17/00, supervision was further increased to being in constant sight by staff during waking hours, and 30 minute checks at night.
During an interview with E5 on 8/21/00 at 11:35 a.m., he stated that "constant supervision" of R12 went into effect on Home 2 on 8/17/00.
Following the 2/20/00 incident investigation, 2 more incidents of sexual abuse by R12 occurred (8/2/00 and 8/3/00) before action was taken at DT to prevent further abuse. Even after the 8/2/00 and 8/3/00 incidents, the facility still failed to intervene to protect individuals at the residence from further potential abuse.
R12 resides in Home 2 at the facility.
Seventeen other individuals reside in Home 2. Per a facility information list, 7 of those individuals are severely mentally retarded and 10 profoundly mentally retarded. Of these 17 individuals, some are non-verbal, of small stature, blind and non-ambulatory, making them vulnerable to those who are aggressive.
In an eight-month period (12/17/99 - 08/03/00) R12 has sexually abused 4 individuals. The facility failed to put safeguards in place to protect these individuals and an unknown number of potential victims at the facility and DT from abuse.
R12, R16, R14 and R15's guardians were not notified, per review of the 4 incident reports. Per interview with E1 on 8/22/00 at 3:15 p.m., no guardians were notified of these 4 incidents.
The facility failed to notify R12's, R16's, R14's and R15's guardians of the above noted incidents of sexual abuse.
A notation on the 8/2/00 incident report indicates that E26 did not receive the report until 1 day later (on 8/3/00). An interview with E8 on 8/17/00 at 2:10 p.m. confirmed that the 8/2/00 written incident report was not received by her until about 4 p.m. on 8/3/00. E8 stated during the interview that she "found out about the 8/3/00 incident before (she was notified of) the 8/2/00 incident." E1 and E27 confirmed they were notified of the 8/2/00 incident on 8/3/00.
An 8/2/00 11am incident of sexual abuse at Eldridge DT was not reported to E26 and E1 until the next day (8/3/00). In the interim, a second sexual assault by R12 occurred on 8/3/00. The 8/2/00 incident was not immediately reported to the administrator.
No documentation of Illinois Department of Public Health (IDPH) notification was evident on the 4 incident reports. An interview with E1 on 8/22/00 at 3:15 p.m. confirmed that none of these 4 incidents were reported to IDPH.
The facility failed to immediately report 1 incident of sexual abuse to the administrator. The facility failed to notify IDPH of 4 incidents of sexual abuse.
II R11 is a 42-year-old male diagnosed with Severe MR and Bipolar Disorder. Per record verification, an Injury Report dated 7/14/00 11:15 p.m. notes R11 to have "Discoloration around left eye and right side of forehead, scratches (2) on top left side of head." An Incident Report also dated 7/14/00 11:15 p.m. noted R11 alleged a staff "pushed him down on the sofa and put water on him, also stated he was hit in the face with a wet towel."
Per record verification and interview of E2, 8/16/00 at 3:07 p.m., E25 was the staff who was first made aware of R11's allegation of abuse and injury of unknown origin. R11 directly told E25 of the alleged abuse on 7/14/00 at 11:15 p.m. E25 did not notify Administration of the allegation of abuse and injury of unknown origin until 7/15/00 at 6:30 a.m. E2, interviewed 8/16/00 at 3:07 p.m, stated E25 "should have called Administration immediately - did not follow proper procedure."
Per record verification the facility investigated R11's allegation of physical abuse and their report dated 7/18/00 notes, "There was no findings of abuse." The investigation also recommended "The reporting staff (E25) be reminded that the immediacy of the report is essential regardless of the day or hour of the report."
The facility failed to ensure that R11's allegation of abuse was reported immediately to the Administrator. (A)