Statement of Violation

Swann Special Care Center

Facility I.D. Number: 0035485
109 Kenwood Road
Champaign, Illinois 61820

Date of Survey: 10/03/2003

Incident Report Investigation of September 28, 2003

"A" VIOLATION(S):

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 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)

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)

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. (Section 3-611 of the Act)

These regulations are not met based on the following:

1). Based on interviews and file verification, there is evidence that individuals in the facility have been sexually abused and the facility has not taken steps to protect them and/or to prevent reoccurrence affecting R1, R2, R3 and R4 with the potential to affect 108 of 108 individuals who reside in the facility.

According to his employment records, E3 had originally began employment as a teacher/assistant teacher in the facility school program with a hire date of 10/3/90. E1 confirmed on 10/3/03 at approximately 8:40 a.m. that E3 began working on the night shift as a direct care staff member of the facility in 9/2000. According the Nurse Aide Registry at the Illinois Department of Public Health, E3 received certification as a Developmental Disabilities Aide on 5/22/93 and as a Child Care Aide on 3/5/99.

When interviewed on 10/01/03 at approximately 9:15 a.m. E1 (Administrator) stated that on Sunday (9/28/03) morning at about 9:00 a.m. she received a telephone call at her home from E4 (Nights CNA, Supervisor). E1 stated that E4 told her that at approximately 5:30 a.m., she had been making rounds and was looking for E3 (Direct Care Staff). When she (E4) looked into one of the team rooms, she noticed that the bathroom door was closed and could see light under the door. When E4 opened the door, she observed R1 on a toileting commode. E1 stated that E4 told her that E3 was standing immediately in front of R1 and was facing her. E4 told E1 that when she called E3's name, he turned away from her with his back to her (his side to R1) and that she could see his elbows moving and that she heard a snap. E1 further stated that E4 assisted E3 in getting R1 back into bed and with personal care for another resident prior to the end of the shift when they both clocked out at 6:00 a.m. E1 stated that E4 then went to her home, wrote a statement of what she had seen and called her.

E1 continued to say that when the police interviewed E3 on 9/28/03, E3 admitted that on two previous occasions he had massaged R2's genitals while she was on a bathing gurney sometime in 2002. E3 also admitted to having masturbated R3 three times and having performed oral sex to E3 on three occasions for a total of six incidents. E1 stated that E3 told the police that this was the first time he had had sexual contact with R1 and that he had just unzipped his pants and was just beginning to masturbate when E4 walked into the bathroom.

E1 stated that they immediately started retraining staff on their abuse and neglect policy on Sunday afternoon (9/28/03.) She said that immediately following the Sunday inservice, E5 (Direct Care Staff) told her that about one year ago while working at night, he (E5) had entered a bathroom, had observed E3 standing over R4 on a bathing gurney and had appeared to be having oral sex.

A. E5 was interviewed on 10/1/03 at approximately 4:20 p.m. accompanied by E6 who provided interpretation for E5. E6 explained that E5 has trouble speaking and interpreting the English language and is unable to read. She stated that E5 had come from China in 1999. Through interpretation as E6 for spokesperson, E5 stated that it was maybe in 2001 that he was working on the night shift. He said that he had

gone into Team 1 to get some tape. When he went into the bathroom, he saw that R4 was naked on the bathing gurney and E3 was leaning over R4. E5 stated that E3 had his mouth over R4's penis. He stated that when he looked at E3's face, he was "still smiling," and that though he thought it was strange and he was frightened, he did not know that it was something wrong at the time so he did not report it. He thought that it might have been something that was OK here. E6 further stated that in their country, they "don't really notice those kinds of things, only after coming to this country do they hear of this." E5 then stated that after this time when people were talking about the abuse, he realized that what he had observed was bad and told E1 on 9/28/03. E6 stated that there are 12 people from China currently employed at the facility.

Per interview with E7 (RSD) on 10/1/03 at approximately 2:15 p.m., E7 stated that she is comfortable with the preparations (training) she has received regarding sexual abuse - that she has the confidence to report though some people might not. She stated that E5 may not have come forward partially because of culture, that our culture can be confusing to some people from other cultures, that sexuality is difficult to talk about, and that though they may think it is an odd thing, they may not know it is illegal. E7 also added that she is "involved in training of employees and feels that employees have listened and have asked questions..."

Per review of staff training records, there is no evidence that staff from other cultures have received any special training regarding cultural difference/importance of feeling comfortable and safe in reporting their concerns and dealing with the potential language barriers. Confirmed by E1 during discussion on 10/01/03 at approximately 4:00 p.m.

B. When interviewed on 10/1/03 at approximately 9:15 a.m., E1 stated that she had gotten a phone call from E4 at approximately 9:00 a.m. on 9/28/03 reporting that she had observed E3 as described above. E1 stated that E4 had clocked out at the normal time (6:00 a.m.) and had gone home to write her statement prior to calling her (E1). Confirmed per interview with E4 on 10/2/03 at approximately 8:15 a.m. Per a statement written by E4, it stated, "Due to the delicate nature of this situation I did not report what happened to anyone prior to my discussion with <E1>."

Per review of the facility policy #36, under Procedure, 1., it states that incidents of abuse should be reported within one hour. However, under 7. A., it states that the facility shall, "Ensure the immediate health and safety of involved individuals..."

There is no evidence that E4 immediately reported the suspected abuse of R1 by E3 to the Administrator or her designee to ensure the safety of the residents of the home. In addition, E4 failed to follow the facility policy to notify the Administrator within one hour of an observation of suspected sexual abuse.

Per review of facility policy #36 regarding abuse, it states that the facility shall immediately take steps to, "Ensure the immediate health and safety...by removing alleged accused employee(s) from having contact with the involved individual(s)..."

There is no evidence that E3 was immediately removed from providing care for residents pending investigation of E4's suspicions of sexual abuse of R1 by E3.

C. Per interview with E1 on 10/1/03 at approximately 9:15 a.m., she stated that on 9/28/03 following an abuse neglect inservice, E5 told her of an incident when he had seen E3 having oral sex with R4. In addition during the interview, E1 stated that when the police interviewed E3, E3 admitted to having sexual activities with R2 and R3.

When discussed with E1 on 10/1/03 in the late afternoon, E1 confirmed that she had not notified the Illinois Department of Public Health (IDPH) of the three incidents of alleged sexual abuse.

Per review of the current facility policy #36, under Procedures, 7. G., it states that IDPH will be notified immediately.

There is no evidence that the alleged sexual activity involving E3 with R2, R3, and R4 had been reported to IDPH prior to surveyor discussion with E1 as noted above.

D. When interviewed with E1 on 10/1/03 at approximately 9:15 a.m., E2 stated that after E3 and E4 left at the end of their shift (6:00 a.m.), R1 was toileted, bathed, fed and changed from her pajamas to clothing for the day. E2 stated that R1's "pajamas had already gone through the laundry."

Per review of the facility policy #36, under Procedures, 7. B. and E. regarding abuse and neglect, it states that the facility shall immediately, "Secure the scene of the incident and preserve evidence..." and, "Secure all relevant physical evidence, such as clothing..."

There is no evidence that the facility staff followed their policy to secure the scene of the incident and to preserve clothing as per their policy.