WESTLAKE HOME I.D. Number 0036319 2090 W. LAKE DRIVE SPRINGFIELD, IL 62231 As a result of a survey conducted by representative(s) of the Department, it has been determined the following violations occurred. "A" VIOLATION(S) NO RESIDENT SHALL BE DEPRIVED OF ANY RIGHTS, BENEFITS, OR PRIVILEGES GUARANTEED BY LAW BASED ON THEIR STATUS AS A RESIDENT OF A FACILITY. 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 as well as the safety of other resident and employees of the facility. The regulations are not met as evidenced by the following: The facility failed to organize itself in such a manner that it proactively assured individuals are free from serious and immediate threat to their physical and psychological health and safety. Based on review of previous 6 months of incident reports and interviews the following clients were victims of aggression and/or were the aggressor toward peers: R 1, R 3, R 4, R 5, R 6, R 7, R 8, R 10, R 11, R 13 and R 14. R 10 is a 31-year-old male who was admitted to the facility 1-28-99 with a diagnosis that included profound mental retardation, autism and seizure disorder. R 10 was admitted to the facility with a known history of severe and intense physical aggression. The facility failed to organize itself to provide adequate and effective supervision for R 10 to prevent aggression toward others. R 10 had 3 major episodes of intense physical aggression toward others from 2-8-99 to 2-17-99. Incidents on 2-8 and 2-12-99 caused R 10 to be transported per ambulance to the emergency room. Per interview with E 1, R 10 was transferred from an area 16-bed group home to a hospital for a psychiatric evaluation during 10/98 as a result of physical aggression. Per E 1, the group home would not readmit R 10 due to intense behaviors. R 10 was discharged to live with his mother. Per E 1, the mother sought placement for R 10 due to unpredictable explosive physical aggression. R 10 received Depakote 1750mg and Tegretol 1300 mg daily for seizure disorder and physical aggression at the previous group home. The medication was monitored by a neurologist. R 10 was admitted to the current facility with prescribed medications of Risperdal 2 mg daily, Depakote 1750 daily and Tegretol 1500 mg daily for seizures. Per E 2, R 10 was started on Risperdal for aggressive behavior a few weeks prior to admission. E 2 said they thought the facility could "handle" R 10's behavior because he had success in a smaller facility and was now receiving a new behavior modifying medication. Per the "INTEGRATED PLAN FOR THE USE OF PSYCHOTROPIC MEDICATIONS" written 5-9-98 R 10's "aggressive episodes can be very intense; he usually will strike several people in an episode, often leaving visible signs of injury. This poses a safety risk to others as well as to himself." At the time R 10 was admitted to the facility, the facility had 8 other clients who exhibited physical aggression. Per interview with E 2 and review of R 10's behavior plan, R 10's behaviors of physical aggression, destruction of property and self-injurious behavior decreased when he was placed in a small group living environment in California but the behaviors "increased dramatically when he moved to a group home (16-bed) in Illinois." Per record verification R 10's "behaviors increase in frequency and intensity when his routine in interrupted." The record indicated behaviors can be triggered by increase in environment stimulus such as meals. R 10's behavior plan included a crisis management intervention that includes the use of CPI techniques that included physical restraint. Per interview with E 2, only 2 of the staff at the facility are capable of implementing the crisis intervention technique due to lack of direct care staff training in the technique. On 2-8-98 R 10 became aggressive after staff attempted to shave him. He tore up a pillow, did not respond to "relaxation techniques" outlined in the Behavior Plan. R 10 continued to hit the wall, threw himself on the floor, slammed and hit the door, threw things around, kicked R 5 in the stomach, hit her twice with his elbow, hit R 14, hit and kicked 3 staff members. R 2 was kicked in the leg when staff were "moving other residents". R 10 was taken by ambulance to the emergency room and returned to the facility that evening. The facility provided no additional monitoring or supervision for R 10 to prevent further abuse and protect the other clients. Per the facility report, on 2-12-99 R 10 became agitated at the dinner table due to another client's loud behavior. R 10 was redirected to his room to calm down. R 10's roommate, R 4, had also been directed to his room to calm down by a different staff. R 10 hit R 4 twice and then left the room. Attempts to direct R 10 were unsuccessful. R 10 then left the room and hit R 5 before she could be moved. R 10 returned to the dinner table and hit R 7 and R 11 and 2 staff members. Per the report R 10 continued to be aggressive and un-redirectable and was again transported to the emergency room per ambulance. Per facility report, on 2-17-99 R 10 had similar unpredictable explosive behaviors at the workshop lasting from 11 a.m. until 12:45 p.m.. The incident was triggered when he wanted pudding. He pushed 2 male peers, hit himself on the arm and chest, kicked and hit clients and staff, ran in the hall, hit the snack machine with his fist, was restless and pacing. Additional staff were called to assist with the behaviors and he was directed to a quiet room. The facility failed to review and revise active treatment strategies that had proven to be ineffective for R 10's aggressive behavior. On 2-18-99 at 1:30 p.m. a SERIOUS AND IMMEDIATE THREAT was called due to facility failure to uphold client rights whereby harm or injury could result. The threat was removed on 2-19-99 at 3:30 p.m. following submission of an acceptable plan of correction that included 1:1 staffing for R 10. 2. Individuals are involved in serious incidents (i.e. injuries) caused by monitoring systems that are absent or are inadequate to prevent such incidents. Examples include: A. R8 had the following injury reports completed by facility staff: 8/1/98 - Physical aggression by and to a peer for 45 minutes. 9/15/98 - Hit in mouth by peer causing a split lip and gum 10/3/98 - self injurious behavior biting hand for 20 minutes 11/24/98 - hit in head by a thrown ashtray 11/28/98 - Bit hand causing it to bleed 12/6/98 - 1p.m. hit in face and in the right eye by a peer and at 5 p.m. was hit on head and hair pulled by peer. 12/23/98 - Hit two times by peer without any reason 1/16/99 - Bit left hand and arm - deep teeth marks 1/16/99 - Physical aggression to peer and staff for 45 minutes. B. R14 had numerous injury reports completed that reflected that he demonstrated physical aggression towards peers and staff. They in include: 8/9/98 - Hit peer with fist 9/15/98 - Hit peer in mouth 9/11/98 - Struck peer with his crutches 11/24/98 - Hit peer in face 12/6/98 - 1p.m. and again 5p.m. hit peer 12/2/98 - Threw a lamp across the room 1/18/99 - Hit peer with crutches 1/22/99 - Physical aggression against peer 1/22/99 - Hit peer with crutches 1/31/99 - Hit peer with crutches and was physically aggressive towards staff. Other examples are available for R1, R3, R5, R6, R9, and R13 to reflect that they are either recipients of aggression or the aggressor. The facility failed to ensure that individuals are not subjected to peer to resident to resident abuse.