Facility I.D. Number 0044610
Date of Survey:06/20/02
Notice of Violation:09/13/02
Complaint Investigation 0252825
The facilitys 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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)(A,B)
A FACILITY EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR. (Section 3-610 of the Act)
EMPLOYEE AS PERPETRATOR OF ABUSE - WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT AN EMPLOYEE OF A LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT EMPLOYEE SHALL IMMEDIATELY BE BARRED FROM ANY FURTHER CONTACT WITH RESIDENTS OF THE FACILITY, PENDING THE OUTCOME OF ANY FURTHER INVESTIGATION, PROSECUTION OR DISCIPLINARY ACTION AGAINST THE EMPLOYEE.
1) During interviews with facility staff on 06/14/02 and 06/18/02, two staff members of the facility (E4 and E12) stated that they had observed E3 abuse three clients (R1, R2, and R4) of the facility, but had not reported these incidents of abuse to the Administrator per facility policy. While completing interviews with facility staff on 06/14/02, three other staff members of the facility (E5, E6, and E11) stated that they had observed E3 abuse three clients (R1, R2, and R3) of the facility. All three of the staff stated that they had reported these incidents of abuse to the nurse and/or Assistant Administrator who did not inform the Administrator of these reports.
Interview with E4 (Direct Care Staff) on 06/12/02 at 2:22 P.M., E4 stated that she had observed E3 pushing R3 away from the activity room door. E4 confirmed that she saw E3 using a type of pressure control technique. E4 did not remember when the incident occurred. E4 stated that the incident had occurred "sometimes last week (prior to 6/12/02). E4 stated that she was walking through the activity room to go outside for her break. E4 stated that she saw "E3 push R3 using (his) three fingers (of both hands) by pushing into the indention of R3's shoulder blades." E4 stated that "E3 did not remove his fingers from R3's shoulders until he pushed her all the way to the steps in the activity room." E4 stated that she did not report this to the administrator. E4 stated that she "should have reported" this incident. E4 stated that "E3 threatened me and said if I told, he could get me fired."
During this interview, E4 also stated that she had seen E3 place R1 in a bear hug. E4 stated, "When R1 refuses to do something, E3 would place his arms around her chest and pick her up off the floor." E4 stated that she thought this type of hold was a form of a restraint. E4 stated that she had also seen E3 bear hug R1 all the way from her room to the bathroom without her feet touching the floor. E4 also stated that on 02/28/02, she reported that R1 had marks on her back. E4 stated that "R1 looked like she had been beat with poles." A week later, E3 told me (E4) in the break room how R1 got the marks on her back. He (E3) said that he had pushed R1 up against her bed to keep her from attacking him." E4 stated that she had not reported this to her supervisors because of "threats" made by E3.
Per interview with E12 (Direct Care Staff) on 06/18/02 at 3:20 P.M., E12 stated that she had observed E3 being "rough with R4. E12 stated that this had happened in the dining room at dinner time, however she could not recall the date. E12 stated that R4 was "throwing a fit" so "E3 pulled him roughly by both arms up from his chair." E12 also stated that she had observed "E3 bear hug R1 to get her to the shower." E12 stated, "E3 puts his arms around her in a basket hold and picks her up. While being held, R1's feet do not touch the floor." During this interview, E12 confirmed that she had not reported E3's actions to her nurses supervisors.
Per interview with E5 (Direct Care Staff) on 06/14/02 at 2:50 P.M., E5 stated that she had witnessed E3 abusing clients of the facility, but could not recall the specific date(s). E5 stated, "I was in the shower room shaving R1 and R2 was in the room. E3 came into the shower room and yelled at R2 to sit down. E3 then grabbed R2 by his arms and sat/pushed him down hard in the chair." E5 stated that she left the shower room and reported this to the nurse on duty. E3 stated that she did not remember the nurses name. During this interview, E5 stated that she had also seen "E3 pick R1 up in a bear hug from behind." E5 stated that when E3 gets "in a bad mood, he gets too rough with the clients." E5 also stated that she became concerned when E3 was placed on one on one supervision with R1. E5 stated, "I was afraid of what might happen to R1 with E3 working one on one with her."
Interview with E9 (Nurse)on 06/14/02 at 6 P.M. verified that E5 had talked with her about E3 being "too rough" or "talking rough" to the clients. E9 stated that she could not remember when this happened. E9 stated that she had talked with E3 and that he had denied being rough with the clients. E9 stated that she did not document E5's allegation, nor her talking with E3. E9 stated that she did not recall E5 telling her that E3 had grabbed R2 and pushed him down in a chair. E9 stated that she did not assess R2 after talking with E5. E9 confirmed that she had not informed the Administrator of the allegation of staff abuse and no further action was taken by the facility.
Interview with E6 (Direct Care Staff) on 06/14/02 at 2:40 P.M., E6 stated "I have seen E3 bear hug R1 and it's not right." E6 stated "I felt like it was abuse." E6 stated that he had reported this to the nurse (E8) and to the Assistant Administrator (E2). E6 could not recall when he had reported the allegation of staff abuse.
Interview with E8 and E2 on 06/14/02 at 3 P.M. confirmed that E6 had talked with them about E3. E2 stated, "E6 came to me and had a problem with something E3 was doing." "I thought it was a squabble." "I talked with E3, but I thought it was insignificant." "I cant remember exactly what we talked about." E2 stated, "I didn't consider it abuse." E2 stated that he was unsure when he talked with E3. E2 stated, "It could have been that day, the next day, or the day after." E2 stated that he did not document the conversations he had with E6 or E3. E2 confirmed that no further action was taken by the facility to address the allegation of potential staff abuse.
Per interview with E11 (Direct Care Staff) on 06/14/02 at 5:25 P.M., E11 stated that she had "seen E3 pick R1 up in a bear hug about a week or two ago." E11 stated that she had informed E8 (Nurse) and she (E8) told me to go talk with E2 (Assistant Administrator). E11 stated that she had told E2 and he said he "already had talked with E3." E11 stated that she was concerned when E3 was placed on one on one with R1.
Interview with E8 (Nurse) on 06/18/02 at 11:20 A.M., E8 stated that she did not recall E11 telling her about E3 placing R1 in a bear hug. E8 stated, "She (E11) could have and I was busy and told her to talk to E2."
Interview with E2 on 06/14/02 at 5:45 P.M., E2 stated that he remembered talking with E11, but "did not recall the conversation. E2 confirmed that he did not document the conversation he had with E11 and that no further action was taken by the facility.
Interview with E2 (Assistant Administrator), E8 and E9 (Nurses) on 06/14/02 and 06/18/02 confirmed that no action was taken by facility staff to thoroughly investigate the allegations of reported staff abuse towards R1, R2, and R3. During these interviews, E2, E8 and E9 confirmed that E3 was not removed from resident contact after they had been informed of potential staff abuse.
Per record review, R1, R2, R3 and R4 all function at a profound level of mental retardation. Speech and Language assessments completed for these individuals identified that neither R1, R2, R3 or R4 have the communication skills to inform staff or others that they have been abused and/or mistreated.
Per record review for R1, R2, R3 and R4, no documentation was noted that identified any of the reported incidents of abuse and/or mistreatment by facility staff. No documentation was noted that nursing staff had assessed the client(s) for possible injury after being notified by facility staff.
During an interview with the Administrator (E1) on 06/14/02 at 4:30 P.M., E1 stated that she was not aware of any allegations of staff abuse until brought to her attention by the surveyor on 06/14/02.
Interview with E1 (Administrator) on 06/18/02 at 11:40 A.M. confirmed that staff of the facility did not follow the facility's policy and procedures on reporting and investigating allegations of abuse. E1 stated that she had not been made aware of allegations involving E3 until brought to her attention on 06/14/02 by the surveyor. E1 stated that further staff training was needed to assist all staff in reporting, investigating and documenting allegations of abuse as per facility policy.
On 06/14/02, at 8:30 A.M., E3 (Direct Care Staff) was observed working in the activity room of the facility. Clients were present in the activity room. E3 was not observed to be monitored by staff.
2) The governing body failed to ensure that the facility implemented their own policies and procedures to assist in the prevention of abuse and neglect against clients of the facility.
Per review of personnel files on 06/14/02, the surveyor reviewed the background check information for E3. Review of this information dated 10/04/2001 identified that finger prints were required to complete the background check. No further information was located in the personnel file.
Interview with E2 on 06/14/02 at 3:15 P.M. confirmed that no further action had been taken by the facility to complete the request for finger prints as requested. E2 confirmed during this interview, that E3 has continued to work at the facility without interruption.