Facility ID Number 0037895
7050 Madison St.
Willowbrook, IL 60521
Date of Survey:03/15/01
The licensee and the administrator shall be responsible for seeing that the applicable regulations are met in the facility and that employees are familiar with those regulations according to the level of their responsibilities.
The facility shall follow their written policies and procedures in operating the facility.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
A facility administrator, employee, or agent who becomes aware of abuse or neglect of a resident shall also report the matter to the Department.
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.
These requirements are not met as evidenced by:
Based on observation, record review and interview, the facility administration failed to implement the facility policy on Abuse Prohibition (effective since 6-1-96) to prevent multiple episodes of sexual abuse of 4 cognitively impaired female residents (R1, R4, R5, R6) by 2 alert male residents (R2, R3) between November 1999 and March 2001. The facility administration and employees failed to:
(1) Intervene when multiple incidents of resident to resident abuse occurred.
(2) Monitor and supervise the behaviors of 2 male residents (R2, R3) as recommended by Z4.
(3) Thoroughly investigate the circumstances surrounding the witnessed sexual abuse of 4 female residents (R1, R4, R5 and R6 ) by two male residents (R2 and R3).
(4) Notify the state Department of Public Health of 9 out of 10 abuse allegations.
1) R2 is an 84 year old resident admitted to this facility on 5-14-97 with diagnoses of chronic obstructive pulmonary disease, alcohol abuse, degenerative joint disease, constipation, history of cancer of the colon, history of pneumonia and multiple rib fractures.
R2's 2-13-01 quarterly Minimum Data Set (MDS) assesses R2 as having long and short term memory problems but as being alert and oriented to his name, the time and the place. On this assessment, R2 is evaluated by nursing as being able to understand and as being able to make himself understood.
According to psychiatric evaluations by Z4, R2 is "psychiatrically stable." An evaluation written on 12-22-99 reads, "I was asked to see this patient on an urgent basis today as he was found with a naked female resident on his bed yesterday." "Impression=Inappropriate sexual behavior which is under patient's control. For the benefit of female residents on the unit, patient should be moved out of the unit."
Per Z4's recommendation, on 12-22-99, R2 was transferred from the the Alzheimer's unit. However, five months later on 5-23-00, R2 was transferred back into the Alzheimer's unit and placed in a private room.
At 10:30 A.M. on 3-12-01, surveyor spoke with Z4 on the telephone regarding his account of R2. Z4 said that incidents of sexual abuse of R2's nature don't happen in long term care facilities "that often" so Z4 said he is very familiar with R2. Z4 said, "(R2) is a very difficult personality; he knows exactly what he is doing. (R2) may act like he doesn't. (R2) is not depressed. (R2) is just unmotivated and likes to stay in bed. (R2) is an opportunistic person. (R2) was, at one time moved to the facility's first floor. I don't know why he was moved back to the dementia unit. (R2) did not belong there."
During interview with E3 at 9:40 on 3-7-01 in the facility private dining room, E3 described an 11-16-99 incident in which a cognitively impaired female resident, R4, who resides on the Alzheimer's unit was found undressed in a male resident's room (R2). Review of R4's nursing notes of 11-16-99 confirmed the incident reading, "Resident found in male resident's room with no shirt and bra unclasped. Redressed and removed from room." According to the facility "Resident Status History Listing", at the time of this incident, R2 was 4 doors away from R4. E3 went on to say that due to R4's severe cognitive deficit, R4 consistently wandered and often wandered into R2's room.
During interview with E4 in room 233 at 10:15 A.M. on 3-7-01, E4 described R2 as having to be closely monitored because R2 would call female residents into his room. E4 said that R2 had several inappropriate sexual encounters with a confused female resident, R4, who was ambulatory and wandered around the unit.
During interview with E5 in room 233 at 3 P.M. on 3-7-01, E5 described R2 as "not confused" and having no psychiatric diagnosis. E5 related an occasion in November of 1999 when she caught R2 fondling the breasts of R4. E5 said that she felt R2 saw R4 as "easy pickings." E5 said that R2 rarely left his room. Instead R2 would lie in his bed and motion for passing female residents to come in.
The following incidents are witnessed occurrences that are documented in R2's medical record since September 8, 2000:
At 8:00 P.M. on 9-3-00, R2's nursing notes read, "Resident constantly luring women into his room. This nurse heard him telling female resident, 'Take your pants off.'.... Third time tonight staff had to remove confused female residents."
At 7:00 P.M. on 9-8-00, R2's nursing notes read, "Female resident found in bed with resident in his room. Hand down female resident's pants."
At 5:45 P.M. on 9-13-00, R2's nursing notes read, "Resident sitting in hallway. Female resident standing in front of him. Resident with his hands up her shirt fondling her breasts."
According to E9 during telephone conversation at 3:15 p.m. on 3-13-01, the female resident involved in the 09-03-00, 09-08-00 and 09-13-00 incidents was R4.
According to the facility "Resident Status History Listing", on 11-22-00, R2 was moved from private room 236 which is in close proximity to and visible from the nurses station and transferred to room 246. Room 246 is located at the far end of a hall and not visible from the nurses station.
At 10:00 P.M. on 1-11-01, R2's nursing notes read, "CNA reported that female resident was found in (R2's) room semi-nude and that resident was touching her private parts. When CNA spoke to (R2) he said, 'We were just kissing.' Will inform social service."
At 10:00 A.M. on 2-18-01, R2's nursing notes read, "Resident's family member reported seeing another resident doing oral sex. Report to social service. Female resident removed from resident's room."
At 10:45 A.M. on 3-07-01, surveyors spoke with Z1 in the administrator's office. Surveyors asked Z1 to give them an account of what he saw between R2 and R1 on 2-18-01. Z1 said, "On the morning of 2-18-01, I passed (R2's) room and glanced in to see a female resident standing by (R2's) bed. I knew that (R2) had bothered a female resident in the past. I walked by again and saw the female resident leaning over (R2's) bed and saw (R2) taking off his black gloves. When I passed a third time, (R2) was lying on the bed and (R1) was giving him oral sex. I heard (R2) say, 'Oh, you're good; boy, you're really good.' I looked for staff assistance and found (E6). (E6) went directly to (R2's) room and removed (R1) from (R2's) room and then I told (E4)."
At 10:05 A.M. on 3-07-01 in room 235, surveyors interviewed E6 regarding his account of the incident between R2 and R1 on 2-18-01. E6 said that "(Z1) called to me while looking for a nurse. (Z1) told me there was a problem in (R2's) room. I went directly to (R2's) room. Upon entering (R2's) room I saw (R1) kissing (R2) on the cheek. Both residents were fully dressed when I saw them. I removed (R1) from the room."
At 10:15 A.M. on 3-07-01, in room 235, surveyors interviewed E4 regarding her account of the aforementioned incident between R1 and R2. E4 said Z1 approached her and told her what had taken place in R2's room. E4 said when she arrived at R2's room, R2 was sitting on the side of his bed fully clothed. R1 was not in R2's room.
2) R3 is an 83 year old male admitted to the dementia unit on 10-3-99. On 11-09-99 R3 was transferred to the dementia unit and has remained there until he was transferred off the unit on 3- 3-01. R3's diagnoses include Chronic Obstructive Pulmonary Disease, Cerebral Vascular Accident with language deficit and Diabetes Mellitus. Since admission, the facility per the MDS, has been indicating R3 is moderately cognitively impaired.
During interview with E1 in the facility's private dining room on 3-7-01 at 3:30 P.M., E1 stated "R3 was placed on the dementia unit to secure him from wandering." There is nothing in R3's MDS or the nursing notes to indicate he had wandering behaviors. R3 was mobile on the dementia unit by propelling his wheelchair independently per the MDS dated 10-99.
During a phone interview with Z4 on 3-12-01 at 10:30 A.M., Z4 stated he spoke with R3 approximately one week ago. Z4 stated, "(R3) is a resident who knows what he is doing. (R3) has some cognitive impairment but he understands what he is doing. (R3) thinks it's fun."
Interview with E5 in room 233 at 3 P.M. on 3-7-01 indicated that "(R3) had problems with his speech, but he knew what was going on and what he was doing."
R3's nursing notes indicate a pattern of inappropriate sexual activity
towards female residents which was first documented on 2-8-00.
2-8-00 "found touching female resident's (R6) private parts."
Further notes read:
7-4-00 "found in bed with female resident (R6), sexual activity
10-9-00 "found in bed with female resident (R6) and sexual activity noted."
2-3-01 "found in female resident's room (R6) with female's incontinent pad taken off."
3-1-01 "found in female room (R5), had his hand on her R. (right) breast rubbing her."
Z4's progress notes first mention the inappropriate sexual behaviors of R3 on 5-12-00 and continually documented that the resident was sexually inappropriate and to monitor the whereabouts of R3 .
Nursing notes and social service notes, between the dates of November 1999 and March 2001, document numerous incidences of sexual abuse of confused female residents by R2 and R3. Psychiatric progress notes recommend that R2 be removed from a unit with confused female residents and that R3 be monitored very closely. During interview with direct care staff, surveyors learned of instances of sexual abuse of female residents by R2 and R3 . This had been reported to E3, yet, R2 and R3 remained in a room in far proximity from the nurses station, on a unit with confused female residents . R2 and R3 were known to sexually assault female residents and resided next to an exit door where confused residents were said by E5 to wander.
At 4:00 P.M. on 3-8-01 in the facility's private dining room , surveyors asked E2 and E3, "In light of your knowledge of the inappropriate sexual behaviors of (R2) and (R3) toward confused female residents, why did the facility neglect to move (R2 and R3) from the Alzheimers's unit to an area where females were less vulnerable and R2 and R3's behaviors could be closely monitored"? E2 and E3 did not answer.
Interview with E4 on 3-7-01 at 10 A.M. in room 235 revealed to the surveyors the allegations of sexual misconduct of R2 and R3 had been reported to E3 after each occurrence.
E2 and E3 confirmed with surveyors at 2:45 P.M. on 3-7-01 in the facility's private dining room that they had only submitted two reports of allegations regarding resident to resident sexual abuse to the Department of Public Health. One was dated 2-19-01 involving a 2-18-01 incidence of oral sex between R1 and R2 as witnessed by Z1. The other was dated 3-7-01 involving a sexual act taking place between R3 and R5 on 3-1-01. Surveyors reviewed the notification sent into the Department by the facility on 2-19-01 to discover that it was not specific in its description of sexual abuse of R1 by R2. The transaction to the Department reads, "On Sunday, February 18, 2001 an incident occurred involving two residents. The residents were engaged in an inappropriate behavior." The incident dated 3-7-01 reads, "On 3-1-01, there was an incident of sexual contact between two residents. "
When surveyors asked E2 and E3 for their internal investigations on the aforementioned incidences of witnessed sexual abuses, E3 produced a brief, single, unsigned, typed page describing only the most recent occurrence of 2-18-01.
The Abuse Prohibition policy includes:
(1) Identifying, correcting and intervening in situations in which abuse is more likely to occur.
(2) Having staff report the abuse to the nursing supervisor immediately.
(3) Protecting customers from further harm.
(4) Analyzing all occurrences to determine what changes are needed to policies to prevent further occurrences for all residents in the facility.