RIVERVIEW TERRACE
Facility Name I.D. Number 0039859
201 Spring Street
Rosiclare, IL 62982
Date of Survey: 10/05/01
Notice of Violation: 11/06/01
Special Licensure Survey
"A" VIOLATION(S):
The facility’s governing body shall exercise general direction of the facility, and shall establish the broad policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served.
The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the administrator. The policies shall be available to the staff, residents and the public. These written policies shall be followed in operating the facility and shall be reviewed at least annually.
The facility shall provide training and habilitation services to facilitate the intellectual, sensorimotor, and effective development of each resident in the facility.
There shall be written training and habilitation objectives for each resident that are:
Based upon complete and relevant diagnostic and prognostic data.
Stated in specific behavioral terms that permit the progress of the individual to be assessed.
There shall be evidence of training and habilitation services activities designed to meet the training and habilitation objectives set for every resident.
As appropriate, effective and individualized program that manages residents’ behaviors shall be developed and implemented for residents with aggressive or self-abusive behavior. Adequate, properly trained and supervised staff shall be available to administer these programs.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Sections 2-107 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.
Based on observation, interview, record verification, review of the Resident Council Meeting reports from April to August 30th, 2001, and per review of the Incident Reports from March 2001 to present, the facility has neglected to implement their written policies and procedures prohibiting mistreatment, neglect and/or abuse of the client(s) as evidenced by:
1) the facility neglected to take necessary action to prevent client to client abuse and mistreatment for 3 of 4 clients in the sample (R-1 ,R-2, and R-4) and 5 clients outside the sample (R-8, R-9, R-10, R-14, and R-15) with the potential to impact all clients of the facility who have been abused and/or mistreated by R-16, R-10 and R-12; and
2) the facility neglected to investigate an allegation of staff abuse towards 1 client in the sample (R-4) who was allegedly abused by staff on 08/25/01, having the potential to impact all clients of the facility; and
3) the facility neglected to investigate injuries of unknown origin for 1 of 4 clients in the sample (R-4) and 5 clients outside the sample (R-6, R-7, R-10, R-14 and R-16) having the potential to impact all clients of the facility.
Findings include:
1) Facility neglected to take necessary action to prevent client to client abuse and mistreatment.
Review of the facility's policy and procedures regarding "Handling of Incidents (or Suspected Incidents) of Resident Abuse/Neglect" revealed that "All incidents (or suspected incidents) of resident abuse or neglect must be reported immediately to the RSD/QMRP or Administrator. The RSD/QMRP, Administrator or a combination of the above employees shall investigate the allegation. A report will be prepared, including corrective actions. Reports will be forwarded to external licensing organizations as required by regulation.
In an emergency situation, the RSD/QMRP or Administrator may act prior to an investigation to protect the resident.
Procedure:
Review of the facility's Incident Reports from March 2001 to present during Task II of the survey process, revealed multiple incidents of client to client abuse and mistreatment. Documentation was not identified that the facility had assessed these incidents and/or taken corrective actions to prevent reoccurrence.
a) Record verification revealed that R-16 is a 47 year old male that functions at a severe to profound level and has diagnosis of history of Impulse Control Disorder. R-16 was admitted to the facility on 02/15/01.
Review of the Incident Reports during Task II of the survey revealed that R-16 had multiple documented incidents of going into other clients rooms at the facility and on multiple occasions had removed their clothing off of their bodies while they were sleeping during the night.
Examples included:
Incident Report dated 08/12/01 (Time: 3:00 A.M. ) "R-16 continued to go into other resident's rooms and bother them while they were trying to sleep. R-16 went into R-8's room and took off her night gown twice."
Incident Report dated 08/11/01 (Time: 7:25 P.M.) "I was walking by R-10 and R-16's room. R-16 was taking R-10's clothes off and R-10 slapped R-16 on the back..."
Incident Report dated 07/29/01 (Time: All day) "R-16 kept taking his shirt off and then proceeded to pull male resident's (R-10) shirt off..."
Incident Report dated 06/10/01 (Time: All day) "R-16 kept going into other residents's rooms throwing clothes all over their rooms...bringing clothes to the living room and kitchen, taking his clothes off and changing into whatever he took, then he would take those clothes off another resident and put those on. He would do this several times throughout the day."
Incident Report dated 03/26/01 (Time 3:30 A.M.) "R-16 went into other resident's (R-8) bedroom and tried to take her nightgown off. Staff intervened and R-16 attempted to grab her (staff's) breast and buttocks".
Incident Report dated 03/16/01 (Time 7:25 P.M.) "...We noticed that R-16 had taken a women resident clothes off and was trying to push her in his room." (Incident Report did not identify the women resident.)
Incident Report dated 03/12/01 (Time: 10:30 - ) "...Heard R-16 slamming doors down left wing. R-16 repeatedly turning on lights, trying to hurdle half wall in living room, entering women's rooms, turning on lights and disturbing them. R-16 also stripped his roommates' clothes off of him (R-10), he kept taking all roommates covers and sheets and throwing them in closet leaving roommate naked with no blankets. Staff repeatedly dressed room mate, R-16 repeatedly stripped them off. Staff noticed blood on roommates mouth, lip swelled. Staff unaware of how it happened and roommate appeared to be struggling to keep underwear on upon arrival into their room..."
Incident Report dated 03/02/01 (Time 4:00 A.M.) "He (R-16) got up around 12:00 A.M. or sooner going to each room turning on lights and slamming doors....He had everyone up all night long...he stripped R-10's clothes off and took his covers. R-10 was so upset he started biting himself and acting really nervous. He kept doing this all night. R-1 even had to come and lay down in the living room just to rest...He had everyone up and very upset. It's safe to say no one got any sleep at all. He (R-16) also has been kicking cabinets, getting very aggressive with the staff. Breaking into doors... and if you try to get him to stop, he gets really upset and mad..."
Per review of the Resident Council Meetings minute reports from March 30th to August 30th, 2001, numerous complaints were documented within the minute reports of client complaints against R-16. No documentation was noted within the meeting reports that identified that the facility had reviewed these complaints and taken action to address the client's complaints.
Interviews with verbal female clients of the facility revealed:
Per interview with R-1 from 6 P.M. to 6:10 P.M. on 09/26/01 in R-1's bedroom, R-1 stated that R-16 comes in their bedroom (R-1 and R-15's) and turns on the lights and goes through their things. R-1 stated that R-16 had never tried to undress her because "I run him out". R-1 stated "When we (she and R-15) go to bed , I put R-15's wheelchair against the bedroom door and the thing she props her feet on, I put against the bathroom door". R-1 stated that this doesn't always stop him and "I still have to run him out of here". R-1 stated that "R-16's bedroom is directly next door to mine through the bathroom". R-1 stated that she was upset and that "R-16 makes her mad because she has to block the door to go to sleep".
Interview of R-15 at 6:20 P.M. to 6:25 P.M. on 09/26/01 in the facility living room, confirmed that R-16 comes into her bedroom shared by R-1. R-15 also stated that they block the doors to their room to keep R-16 out "cause you have to". When the surveyor asked R-15 if she had complained about R-16? R-15 stated "they already know about him and it wouldn't do no good".
Per interview with R-9 (who has a room across the hall from R-16) on 09/26/01 at 6:10 P.M. to 6:20 P.M. in R-9's bedroom, R-9 stated "R-16 bothers my clothes and turns everybody's lights on and wakes them up".
R-9 stated that R-16 had tried to take her clothes off and her roommate's (R-8) clothes. R-9 then stated "R-16 did that to R-8 too, and took her clothes off too". R-9 stated that "I didn't like it when he took my clothes off. R-16 is getting worse every day and I'm getting tired of him. You can't get much sleep with him around. I'm kind of scared of him."
Per interview with R-2 (who has a room across the hall from R-16) on 09/27/01 from 9:50 A.M. to 10:05 A.M. in the facility dining room (per the client's request). R-2 stated that "it bothers me when R-16 comes in my room and turns the lights on and wakes me up". R-2 stated "R-16 makes me mad. R-16 comes in my bathroom when I am taking a shower". R-2 then stated that “R-16 has tried to take my clothes off while I'm sleeping." When R-2 was asked by the surveyor if she was afraid of anybody at the facility? R-2 stated "I am sometimes afraid of R-16".
Per interview with the Resident Services Director/RSD (E-1) on 09/25/01 from 10:55 A.M. to 12:20 P.M. in the RSD's office revealed that R-16 is on a behavior program to decrease disruptive behaviors. E-1 confirmed that R-16 also has also had several incidents of attempting to and eloping from the facility. Review of R-16's behavior program with the RSD revealed that R-16's behaviors of stripping others clothing off and elopement were not identified within R-16's behavior program. During this interview, E-1 stated that the facility had "looked at alternative placement for R-16". E-1 stated that "R-16's behaviors had not been considered sexual and that no documented action had been taken by the facility". E-1 confirmed that no action had been taken by the facility to address the clients complaints regarding R-16 that had been lodged during the Resident Council meetings from March to August of 2001.
During this interview, E-1 provided the surveyor with a copy of a report dated 04/30/01 regarding recommendations from Technical Assistance from the Illinois Department of Human Services (DHS) regarding R-16's behaviors. Recommendations were identified for data collection, psychiatric evaluation, utilization of 1:1 staff from 9:00 P.M. to morning to assure that others will be allowed uninterrupted sleep and snacks at bedtime and at midnight. E-1 stated that a psychiatric evaluation had been completed but no further action was taken by the facility to address the recommendations by Technical Assistance (from DHS) made in April of 2001 to address R-16's behaviors.
b) Per record verification, R-10 is a 34 year old male that functions at a severe to profound level and has diagnosis of Impulse Control Disorder.
Review of the Incident Reports from Day Training and the facility from March to August 2001, revealed that R-10 has had multiple incidents of physical aggression towards clients and staff and that R-10 also damaged property.
Review of an Incident dated 07/24/01 from Day Training revealed that R-10 shoved a client from another facility down. The other client sustained a black eye, a busted lip and bruises to the face, arm, and legs. Documentation identified that the client from the other facility was taken "to the doctor to be checked out. Client badly bruised".
During Day Training observation on 09/25/01, interview with Z-1 (Day Training Director) at 1:25 P.M. to 1:40 P.M. revealed that R-10 had to be kept on 1:1 supervision while at DT due to his behaviors.
On 09/26/01 during P.M. observations while at the facility from 3:30 to 6:30 P.M., R-10 was observed to be on 1:1.
On 09/27/01 from 9:30 A.M. to 11:30 A.M., R-10 was not observed to be on 1:1 staff supervision. R-10 was observed during this time frame, banging chairs and doors against the walls, hitting staff, biting himself and pushing tables in the dining room.
At 11:10 A.M., R-9 was standing in the dining room talking with the surveyor. R-9 was standing between two dining room tables. R-10 was observed to begin to push the dining room table towards R-9. One staff (E-4) was present in the dining room and was not observed to monitor R-10 closely. R-10 pushed the table towards R-9 and without verbal and physical intervention from the surveyor, R-9 would have been hit in the hip and stomach area by the table that was pushed by R-10. The dining room table pushed by R-10 hit the other dining room table (that the surveyor was sitting at) with enough force to knock the surveyor backwards.
Interview with E-1 (RSD) on 09/27/01 from 11:50 A.M. to 12:25 P.M. revealed that R-10 does not receive 1:1 supervision while at the facility. E-1 stated that they have had problems with R-10 and his behaviors since his admission to the facility on 10/05/00. E-1 verified that no modifications had been made to R-10's behavior program to address his need for increased monitoring and supervision due to his aggressive behaviors.
An additional example is available for R-12 who is 60 year old male that functions at a mild level who has had two documented incidents of aggression towards other clients of the facility without documentation to support that the facility has taken corrective action to prevent client to client abuse and mistreatment.
Review of the Incident Report dated 04/10/01 R-12 found his roommate (R-14) going through his clothes and became physically aggressive. Review of the Incident Report for R-14 dated 04/01/01 revealed that when staff was "clearing the blood away from R-14 eyes, staff noticed a very bad bite on R-14's arm" which required emergency room treatment.
Review of the Incident Report dated 09/11/01 revealed that R-12 had been chasing a staff's truck down the road that then returned back to the facility. "He (R-12) started hitting a resident over and over". (Client not identified.)
2) The facility neglected to investigate an allegation of staff abuse towards 1 client in the sample (R-4) who was allegedly abused by staff on 08/25/01.
Review of the Incident Report dated 08/25/01 revealed that R-12 informed staff that he had witnessed staff doing something with R-4 and had observed staff laying on R-4 doing something to him. Documentation completed by the RSD (E-1) on 08/27/01 revealed that "R-12 has history of making such statements then denying statement's truth".
Per interview with the Resident Services Director/RSD (E-1) on 09/25/01 from 10:55 A.M. to 12:20 P.M. in the RSD's office revealed that no written investigation had been completed by the facility regarding the allegation of possible abuse of R-4 who is blind and cannot defend himself. E-1 stated that she had talked with R-12, but had not talked with the staff in question, nor had R-4 been examined for any signs of possible abuse.
3) The facility neglected to investigate injuries of unknown origin.
Review of the facility's policy and procedures regarding "Investigation of Incident/Accidents of Unknown Origin" revealed that "All incidents or accidents resulting in injuries of unknown origin must be reported immediately to the RSD/QMRP or Administrator. The RSD/QMRP, Administrator or a combination of the above employees shall investigate the allegation. A report will be prepared, including corrective actions. Reports will be forwarded to external licensing organizations as required by regulation.
In an emergency situation, the RSD/QMRP or Administrator may act prior to an investigation to protect the resident.
Procedure:
Review of the Incident Reports from Day Training and from the facility from March 2001 to present, revealed that R-4, R-6, R- 7, R-10, R-14, and R-16 have received injuries of unknown origin during transit from the facility to Day Training and/or at the facility. Review of the Incident Reports for R-4, R-6, R-7, R-10, R-14 and R-16 did not reveal that the facility had investigated the incidents to assist in determining the cause of the injuries and to assist in corrective action as appropriate.
Examples included:
a) Per record verification R-4 is a 37 year old male that is legally blind and can not defend himself from others.
Incident Report dated 04/04/01 revealed that R-4 arrived at Day Training on 04/04/01 with bottom lip swollen and bruised.
Incident Report dated 04/11/01 revealed that R-4 arrived at Day Training with a bump towards left eye/ear and top of right cheek is bruised.
b) Per record verification, R-6 is a 60 year old male that functions at a severe level.
Incident Reports dated 04/09, 04/23, 05/08, 05/25, and 08/31/01 revealed that R-6 had arrived at Day Training with scratches to his face (near his eyes) and to his neck and back areas.
c) Per record verification R-14 is a 62 year old client that functions at a severe level.
Incident Reports dated 05/29/01 revealed that R-14 arrived at Day Training with scratches on the right side of his face.
Incident Reports dated 06/05, 06/12, and 07/05/01 revealed that R-14 had arrived at Day Training with bruising to right and/or left arms and elbows on the forearms and inner aspects of the arms.
d) Per record verification, R-16 is a 47 year old male that functions at a severe to profound level.
Incident Report dated 09/14/01 revealed that R-16 arrived to Day Training with a huge knot on his forehead and several scratches on forehead and face. R-16 was noted to have a bruised and swollen ring finger on his left hand. The facility was notified and R-16 was taken to the doctor by facility staff.
Interview with Z-2 (Assistant Developmental Trainer) on 09/25/01 at 1:50 to 2:00 P.M. at Day Training revealed that R-16 came to work with a "goose eggs or a huge knot right in the middle of his forehead".
Z-2 confirmed that R-16's left finger was bruised and it "looked like he (R-16) got his finger smashed in a door or drawer". Z-2 stated that on 09/17/01,"R-16 arrived to work with two black eyes".
Per interview with E-1 (RSD) on 09/27/01 at 2:20 to 2:45 P.M. in the RSD's Office, E-1 confirmed that she does not complete formal investigations to determine how clients sustained their injuries of unknown origin. E-1 also stated that she does not review and/or investigate injuries of unknown origin that occur during transit to Day Training or at Day Training. Subsequent interview with Z-1 (Day Training Director) on 09/27/01 at 2:15 P.M. in the RSD's office at the facility, confirmed that she does not investigate injuries of unknown origin to determine how they occurred during transit to Day Training. Interview with E-1 confirmed that she has not implemented the facility's policy and procedures regarding investigating injuries of unknown origin.