Facility I.D. Number: 0038349
Date of Survey: 12/20/02
Annual Health & Complaint Investigation
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 residents 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.
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 THE 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.
These requirements are not met as evidenced by:
Based on record reviews and interviews, it was determined that the facility failed to immediately notify the facility administrator and the local law enforcement agency of an allegation of rape/sexual abuse by R4, failed to do a complete and thorough investigation of the allegation, failed to protect residents from further abuse by reinstating the alleged perpetrator which resulted in an allegation of abuse from R6.
1. According to R4's clinical record, this 101-year-old resident has diagnoses which include chronic renal failure, osteoarthritis, severe degenerative arthritis, mastectomy of the left breast (history of cancer), history of colon resection for cancer of the colon, history of bladder cancer, mild abdominal aortic aneurysm, hypertension, history of myocardial infarction, chronic obstructive pulmonary disease, osteoporosis, angina, heart disease, and hemorrhoids. R4's assessment dated 01/24/02; 09/12/02; and 11/28/02 show R4's cognitive status as having modified independence (some difficulty in new situations only).
The care plan dated 09/19/02, shows written documentation by E22 (care plan coordinator), that reads, "This 101 year old remains alert and mentally bright." During interview on 12/18/02, at 2:00 P.M. with E22, she stated, "(R4) was very bright and talkative that day. A pretty good historian. She has a history of real discomfort and gets very anxious at times. I can't recall what type of behavior she had at the time. If (R4's) behavior had been significant, it would have been documented under behaviors. Review of the care plan of 09/19/02, shows the following problem: "(R4) receives anti-anxiety medication: Phenobarbital." Review shows that there are no behaviors specified/identified as being significant problems on the care plan. Another problem lists: "Cognitive deficit (related to) short term memory loss and slightly modified independence." Approach reads: "Allow (R4) ample time to remember, do not rush her."
During interview with R4 on 11/21/02, at 11:10 A.M., in her room, R4 stated, "A male, white, black hair, strong nurse came in at 10:00 P.M. to put ointment on my bottom. He never spoke a word. He put his finger to his mouth. I was in bed. I was lying on left side. What he was doing was from the back. He had a sponge or cloth. He rubbed liquid on my legs and hips and ran it up between my legs. I felt punches up in my abdomen and vagina. I blacked out I hurt so bad. I'm supposed to get ointment on my bottom every night because I sit up all day. He's applied ointment before without me feeling he was doing something wrong. Around 11:00 P.M., I woke up and felt that something was wrong. I screamed, 'The bloody bastard raped me.' And, I don't swear. I felt someone was hurting me internally. I turned the call light on. A nurse came in. I said, 'I need to go to the hospital. I've been hurt.' The nurse said, 'Turn over and go to sleep.' I laid there and cried until 4:30 A.M. (E23) (LPN), came in at 5:00 A.M. to give me medicine. I was scared to death. I knew he (E4, LPN), and (E23) were friends. The next day, I went to the hospital and three doctors examined me. I'm scared to even set in my chair by the window at night. He (E4), could come and shoot me. I've lived 101 years and this happens to me. It's not right. It hurts and burns when I urinate. He would tickle the bottom of my feet and I kept telling him to leave me alone. Ooh, I didn't like that. I felt it was inappropriate for a nurse to be doing that. It is like a horrible dream! I thought about moving to another nursing home but he will or may be working there. I'm scared." Throughout the interview, (R4) would periodically become tearful and cry.
During interview with E9, CNA (certified nurse aide), on 12/12/02, at 3:00 P.M., she stated, "At 11:15 P.M., I heard (R4) scream and holler, 'I've been raped.' I went down to the room. I went to (E12), assistant director of nursing(ADON), five minutes later. I told her to come down to (R4's) room. I told (E12) that (R4) said she had been raped. (E12) went down to the room. She was talking to (R4 )and I left the room."
During interview with E12, on 12/12/02, at 3:23 P.M., E12 stated, "(E9) came and got me sometime around midnight, after 10:00 P.M. and told me (R4) was complaining of burning in her peri area and would I talk to (R4). I asked (R4) what the problem was? She said, 'It felt like I was being raped. Like something was pushed in the rectum and vagina.' I looked. She
was excoriated on the inner thighs and peri-area. I saw that she had a hemorrhoid from the rectum. I told (R4) that (E4) was probably pushing the hemorrhoid in. (R4) disagreed. I made sure she was cared for and she was calm. I went back to the schedules. I did not call (E2, director of nursing), because I was off the next day and I wouldn't see her. I talked to her about this on the 14th, but she already knew about it by then. I didn't call the police. I saw absolutely no injury. That's why I didn't call anyone. There was no incident report ."
During interview with E2, on 12/12/02, at 4:00 P.M., E2 stated, "The first time I heard of that allegation, was approximately, 5:00 P.M. or 5:30 P.M. on the 13th (approximately 17 hours and 40 minutes from the time R4 made the allegation to E12). I had a page to come to the East wing. (R4's) daughter-in-law was out in the hall and talked with me. She told me there had been allegations of something sexually happening to (R4). I then, saw E1, administrator, coming down the hall. We went down to (R4's) room. (R4) said that she had been raped. She said that (E4) did this to her. She said a person came in at 10:00 P.M. rounds and she has been burning ever since and having abdominal pains. We talked about sending her to the hospital for an evaluation. (R4) showed me what it felt like. She gestured with her hands-- one hand pounding into the other, repeatedly. I told her we would send her to the emergency room. No incident report was completed. I didn't call the police because I knew the emergency room would.
That type of allegation certainly sounds like sexual assault. (E4) was in the building and was brought to my office. We told him we were suspending him while the investigation was taking place. He left immediately."
Review of E4's time card report shows that on 11/12/02, he clocked in at 13:48 (1:48P.M.) and clocked out at 22:16 (10:16P.M.); on 11/13/02, the day following the allegation, he clocked in at 14:04 (2:04P.M.) and clocked out at 17:06 (5:06P.M.). For the same day, there are two entries on the card, one for 17:30 and one for 22:30, both with an asterisk (*) behind them. The time card goes on to reflect E4 on 11/16; 11/17; 11/18; 11/19; 11/20; and, 11/21 as being clocked in at 14:00 and out at 22:30 each day with asterisk behind each time entry. During interview with E24, administrative assistant, on 12/12/02, at 2:01 P.M., she stated that the times with the asterisk by them were times she had to clock him in or out. During interview with E2, on 12/12/02, at 4:00 P.M., she stated that E4 was suspended and when he was reinstated he was paid for the days suspended. That is why E24 clocked him in and out. On 11/22/02, the time card shows E4 to be clocked in at 13:37 and out at 22:50 without any asterisk behind the time entries. Review of the conclusion from the facility investigation shows that on November 21, 2002, E1 wrote:
"My (E1) conclusion is that (R4) is confused..........I will reinstate (E4) to nursing duty immediately. Unless criminal evidence from the police department or state crime laboratory demonstrates a criminal act to have occurred, (E4) will be allowed to
perform his duties as a nurse. E4 was reinstated on 11/22/02, with the stipulation that he was to be assigned to work in a different area of the building and would not have direct contact with R4 and would not be performing nursing care of a sensitive nature without another co-worker present.
Review of the facility abuse prohibition policy and procedure shows that a facility employee who becomes aware of alleged abuse of a resident shall immediately report the matter to the facility administrator; that the charge nurse on duty who is first made aware of any allegation of abuse shall take all steps to protect the resident from danger; that the nurse shall call the director of nurses as soon as possible and notify the director of nurses of the alleged abuse and follow the orders of the director of nurses; the nurse shall call the resident's attending physician; as soon as possible the nurse shall do a full body check of the resident and document any injury in the resident's clinical record; the nurse or director of nurses shall complete an incident report regarding the incident; the investigation shall include interviews with all involved parties and potential witnesses, and, statements should be taken from any other person who may have information related to the incident; 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 investigation. The facility failed to follow the above procedures as stated in their abuse policy.
Review of the initial investigation by the facility, dated 11/14/02, shows that E1 was informed of the allegation of sexual misconduct by E2 on 11/13/02 at 4:30 P.M. E1 spoke with R4 and she informed him that E4 had raped her at approximately 10:00P.M. the prior evening (11/12/02). E1 immediately suspended the employee. R4 was sent to the hospital at approximately 7:00P.M. on 11/13/02, to be examined for evidence of a possible sexual assault. The investigation shows that E1 interviewed R4, E4 (alleged perpetrator), E23 (LPN), E9 (CNA), E12 (ADON), E8 (CNA), Z2 (police detective), R20, and, R4's son and daughter-in-law.
The facility investigation lacks the attending physician report, the emergency room report, the emergency room physician report, and, there is no evidence of physicians being interviewed. None of this information was obtained by the facility until the week of 12/16/02.
Based on record review and interviews it was determined that the facility failed to protect R6 from abuse following an allegation of mistreatment by R4 made against the same alleged perpetrator.
2. On 11/28/02, an investigation of unknown origin was initiated by E12(assistant director of nurses). It states: "(R6) was complaining of discomfort in his hand. Nurses noted bruises on (R6's) left hand. Certified nurse aides and nurses were interviewed including (E4). (E4) stated he didn't know anything about (R6's) hand. The facility's investigation conclusion: E12 spoke with E2 (DON) since E1(administrator) was on vacation and unavailable and helped E12 make a determination. Their decision was to monitor R6. They had no reasonable suspicion that abuse had occurred. They decided to document the incident and refer it to the administrator when he returned from vacation. They felt no other action was necessary at the time."A follow up investigation took place on 12/04/02 after E1 returned to work. The investigation states: "(E2) reported that bruises had been noted on the left hand of (R6). (R6) had also complained of discomfort in that hand. Interviews were conducted with (R6) and (E4)."
The interview with R6 shows R6 telling E1 that "(E4) grabbed it. He was trying to get the rope away from me and I wasn't going to give it to him." (R6) pointed to a personal chair alarm. (R6) said, "I had the rope and (E4) grabbed my fingers to get it away from me."
The interview between (E4) and (E1) reads: "I (E1)asked (E4) if he could describe what occurred with (R6). (E4) said that (R6) had the chair alarm in his hand and had taken it off his merry walker. I was trying to get it away from him so that I could put it back on his merry walker for him. I (E1) asked (E4) if he used more force than normal and he responded yes, I had to. R6 wasn't going to give the alarm to me."
The follow-up investigation conclusion states: "I have decided to terminate (E4's) employment with our facility. I do not approve of any staff members using force, regardless of the degree of force to get residents to comply. For this reason I felt it was necessary to terminate (E4's) employment."
Nurses notes dated 11/28/02 at 12:00 noon state: "Resident complaining of left hand being broken. Noted to have purple bruises on all 4 fingers of left hand palm side 4th finger is slightly swollen."
When speaking with R6 on 12/18/02, at 7:40 a.m., R6 showed me his hands and indicated that the ring finger on each hand was hurt. He said: "someone took my hand (indicating the left hand) and squeezed it and said I'm going to twist this off. "
Review of E4's personnel file shows that on 03/13/02, E4 received a written warning notification from E2(director of nurses), for negative behavior which reads: "Several reports of you slamming books, charts, doors, being rude and sharp in speech to residents. This must stop immediately or further disciplinary action will occur. Recommend EAP(employee assistance program). During interview with E2 (DON) on 12/13/02, at 10:30 a.m., E2 (DON) stated that nurses had reported E4. E2 (DON)stated that his (E4) voice quality is gruff. E2 did not know if E4 went to EAP as recommended because it is voluntary and he did not get back with her. E2 (DON) confirmed that the night of 11/12/02, E4 was helping with bed checks.
E4's personnel file also shows that an Illinois State Police background check identified two convictions of battery dated 02/22/90 and 06/27/96; both class A misdemeanors. During interview with E4 on 12/11/02, at 2:35 p.m., E4 stated: "(E2) talked with me regarding the battery convictions shortly after I started working. She wanted to know what they were about and told me they didn't affect my job duties and assignments."