Facility I.D. Number 0036319
2090 W. Lake Drive
Carlyle, IL 62231
Date of Survey 03/23/01
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, 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)
These regulations are not met as evidenced by:
1.) On 3/14/01 at approximately 10:00 A.M., E1, Resident Services Director (RSD) provided the surveyor with a list of clients who she determined to be interviewable. This list includes: R#'s 1, 3, 4, 6, 7, 8, and 10.
The facility failed to ensure clients are not subjected to verbal, psychological abuse or sexual harassment.
Per review of facility policy, it states: " a resident, staff member, or anyone suspecting abuse, mistreatment or neglect of residents should report the suspected incident immediately to the Resident Services Director and Administrator." This policy further states: "The facility shall notify the Department of Public Health within 24 hours of any report of resident abuse, mistreatment, or neglect."
Per interview with Z1 and Z3 on 3/15/01 from 10:45 A.M. to 11:45 A.M. at an area restaurant, Z1 stated she has heard E3 use an inappropriate tone of voice when addressing the clients who live at this facility. Z3 stated she witnessed an incident in which E3 yelled at R7 which caused R7 to cry and leave the area. Per interview with R7 (mild mental retardation), on 3/19/01, at 3:35 P.M. in the dining room, she stated that E3 did yell at her when she was in the living room, trying to see the dog that E3 had brought into the facility. R7 stated the dog was sick and E3 yelled at her to leave the area.
Per interview with Z3 about the previous incident, Z3 stated she notified E1 (RSD) and E2 (ADM) at the time of the incident. Per interview with E2 on 3/19/01 at 12:15 P.M., in the dining room, he confirmed that he was aware of an issue with E3's tone of voice when dealing with clients', but felt that this was not an issue of abuse and did not report the incident.
The facility failed to report alleged incidents of psychological abuse, verbal abuse or sexual harassment to the Department.
Per interview with Z2 on 3/14/01 per phone, Z2 stated that E5 (hab aide) brought pornographic material into the facility which was accessible to clients with histories of sexual abuse, sexual inappropriateness and sexual aggression. Per interview with Z2, stated she had made E1 and E2 aware of this incident. Per interview with E3 (hab aide) and E4 (hab aide) on 3/14/01 at 3:00 P.M. in the dining room, each stated they were aware of the incident. Other clients told them about seeing the book. E4 stated that R7 and R1 told her about seeing the pornographic pictures. R1, per physician's order sheet, has mild mental retardation and per behavior management assessment, has a history of being sexually molested). R1 stated to the surveyor on 3/15/01 at 8:25 A.M., in the hallway, that she had been shown the pictures in this magazine by another client. R1 further stated she didn't like those pictures much, especially since she had been sexually molested in the past.
Per interview with R7, on 3/14/01 at approximately 4:00 P.M., in the living room, R7 stated she had also seen the pornographic pictures and stated they embarrassed her. Per Z1 on 3/15/01 at a local restaurant from 10:45 A.M. until 11:45 A.M. Z1 stated she was aware of R6 (per physician's order sheet states 20 year old with moderate mental retardation) also looking at this magazine. Per R6's behavior management plan, states a targeted behavior is inappropriate touching. Per interview with Z1 on 3/15/01 at 10:45 A.M. to 11:45 A.M., she stated that R6 is being programmed for an inappropriate touching behavior and that she does not feel that R6's exposure to a pornographic magazine is beneficial for this client to reach his behavioral goals.
Per interview with Z3 on 3/15/01 at an area restaurant from 10:45 A.M. until 11:45 A.M., Z3 stated that E5 (hab aide) told her, "you should have seen R2's face" after he showed him pictures in this pornographic book. Per review of R2's physician's order sheet and per behavior management plan, R2 is a 36 year old male with profound mental retardation and a history of public masturbation, and sexual aggression. He receives medication and programming for this behavior, per his current behavior management plan. Z3 stated that she was present during an incident in which E5 was observed to place a broomstick between his legs and while acting as though this was his penis with an erection he attempted to place the broom stick into a staff members mouth. Confirmed per interview with Z2 on 3/14/01 per phone Z2 was present during this incident. A photograph was taken of this incident and observed by the surveyor. R13, female with severe mental retardation, was present in the room at the time of this incident per interview with Z3.
Per interview with Z3, at the same time and location as described above, Z3 stated that E5 (hab aide) was observed to access the computer in the office. Z3 stated R7 (mild mental retardation) requested to use the computer to check her E-mail. Z3 stated that E5 opened the computer and pornographic material was accessed. Per interview with R7, revealed that she did see the pictures on the screen and stated that E5 had brought up the pornographic pictures on the monitor. Per review of R7's Psychological Evaluation dated 7/1/98, states R7 was sexually molested when she was 13 years of age. Per interview with R7 on 3/15/01 in the living room, stated she had been embarrassed by the pictures she had seen on the computer monitor and her face was observed to turn red at this time while being interviewed.
Confirmed per interview with Z3, Z2 and Z1, E1(RSD) and E2 (ADM) were made aware of these incidents.
Confirmed per interview with E1 on 3/14/01 at 11:00 A.M. in the dining room and E2 on 3/19/01 at 12:15 P.M. in the dining room, these incidents were not reported to the Department.
Per review of physician's orders, R2 is a 36 year old male with a diagnosis of profound mental retardation, Seizures, PICA, Non-Compliance, and Sexual Aggression. Per Observation of R2 on 3/14/01 from 3:30 P.M. until 4:35 P.M., he was observed to be ambulatory and verbalize minimally. R2 currently receives Navane for his PICA behaviors, and Depo-Provera for his sexual aggression. R2's Behavior Support Consultation, dated 8/31/99, stated, R2 has behaviors of inappropriate sexual behaviors including sexual aggression and public masturbation.
Per interview with Z2, per phone on 3/14/01, Z2 stated that she has witnessed incidents when E5 (hab aide) would press his body against R2's and hang on R2's leg like a dog. Per interview with E3 (hab aide), on 3/14/01 at 3:00 P.M. in the dining room. E3 witnessed E5 pressing his body against R2's (like with a belly bump) and shove him to the floor. This incident was also verified by Z3, who stated on 3/14/01 at an area restaurant from 10:45 to 11:45 A.M. Z3 stated she has observed E5 belly rub against R2 in this manner and then either pin R2 against the wall or shove him to the floor. Z3 stated, R2 is not allowed to get up until E5 states he can, which lasted approximately 5 to 10 minutes. Z3 also has seen R2 display the behavior of lifting his shirt and say what's in there and R2 will state "it is a baby". Interview with E6, (hab aide) on 3/19/01 at 1:00 P.M. in the dining room, revealed she has also witnessed this behavior by E5. E6 also stated she has observed E5 (hab aide) belly bumping with R6.
Per interview with Z1, Z2, and Z3 at times and locations identified above, each stated that they have informed E1(RSD) and E2 (ADM) of these behaviors by E5. Per interview with E1, she stated that she had a staff member who used to complain about E5 being inappropriate and a bad influence on the clients, however E1 stated she was not aware of the specific issues and no reproducible investigation was initiated. Confirmed by E2, who also stated that he was not aware of the specific allegations.