Statement of Violation

Eldorado Care Center

Facility I.D. Number: 0036624

Third & Railroad Streets
Eldorado, Illinois 62930

Date of Survey: 08/20/2003

Annual Survey

"A" VIOLATION(S):

The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the Administrator, the advisory physician or the Medical Advisory Committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.

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.

Objective observations of changes in a resident’s condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident’s medical record.

The DON shall oversee the nursing services of the facility including:

Overseeing the comprehensive assessment of the resident’s needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.

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. (Section 3-612 of the Act)

This REQUIREMENT is not met as evidenced by:

Based on observations, record review and interviews, it was determined that the facility neglected to assure that residents had an environment that was safe and free from inappropriate sexual behaviors. The facility staff had knowledge of inappropriate sexual behaviors by R-7 directed towards R-8, R-13, and unknown, unidentified residents. The facility had not conducted investigations and had not implemented preventive measures to protect the 12 residents in the locked Alzheimer's Unit. Appropriate and effective interventions were not implemented regarding R-7's sexually inappropriate behavior which resulted in seven incidents of sexual advances towards residents from 02/22/03 to 07/20/03.

The findings include:

R-7 is a 73-year-old resident in the locked Alzheimer's Unit who has been a resident in the facility since 12/11/00. R-7 has long and short term memory problems and is moderately impaired for daily decision making as documented by the most recent quarterly minimum data set dated 05/29/03. Based on observations and the quarterly minimum data set, R-7 ambulated independently and is not interviewable. His only diagnoses is Alzheimer's Disease.

The following incidents were found in the nurses notes, the behavior tracking sheets, or during interviews with staff.

A. The nurses notes for R-7 state for 02/22/03, "Inappropriate sexual behaviors with another resident. Monitor behavior." No other information was given and no incident report or behavior tracking sheet was completed.

B. During an interview on 08/07/03 at 3:10 p.m., E-5, evening licensed practical nurse, stated that she received a report that R-7 was involved in a sexually inappropriate behavior with R-13. Both of these residents have Alzheimer's Disease and neither has the ability to engage in a consensual sexual relationship. E-5 stated that R-7 was found on his knees, pants down and his penis out of his pants over R-13. E-1, Administrator, and E-5 discussed this incident and decided it had occurred between the last week in February and the first week in April, 2003. There is no written documentation of this incident in the medical record on an incident report or a behavior tracking sheet.

C. The nurses notes for R-7 document an entry for 05/05/03, 2 p.m., "Res. (resident) exposed self private parts to staff and other res. (resident)." No other information was given and no incident report or behavior tracking sheet was completed. The facility could not recall who the other resident was in this incident.

D. The nurses notes for R-7 document that on 06/05/03 at 7:15 p.m., "Resident exposed himself (penis) to evening staff member. Later this resident came to staff member trying to touch her without permission." The next nurses note entry documented at 8:20 p.m., "CNA (certified nurses aide) reported that she caught this resident in almost the action with a female resident. This resident had his penis out of his pants and the female resident was just about to put her mouth to his penis. This resident has been told that this was inappropriate behavior. The female resident was taken to her room. This resident was told to stay in his room." There is no incident report. The behavior tracking sheet documents that the incident mentioned above with the additional information that the staff on duty were told that R-7 was attempting to approach other residents and staff all day. The facility could not identify who the female resident was in this incident.

E. The nurses notes dated 06/09/03 at 12 a.m. for R-7 document, "CNA informed nurse that he had walked up to her and said, 'I would like to screw you.' She in turn stated 'You need to go and sit down.' He then proceeded to zip and unzip his pants. She explained to him that this was not acceptable behavior." There was no incident report and no behavior tracking sheet completed for this incident. The facility did not increase supervision nor did they implement interventions so that R-7 did not turn this behavior toward other residents.

F. The 06/19/03, 6 a.m. entry in the nurses notes state, "was seen standing next to another resident's bed with resident in bed - zipping up his pants. question of interaction?". There was no incident report and no behavior tracking sheet completed for this incident. No resident was identified.

R-7 was saying something to the female res when this CNA approached the room but the words were unclear and whispered." There was no incident report done or documentation of this in the medical record. The female resident was not identified.

H. E-8, CNA, stated during an interview on 08/08/03 that she had observed R-7 expose himself once in the dining room to R-8 in July, 2003. Both residents have a diagnosis of Alzheimer's Disease and would not be capable of engaging in a consensual sexual relationship. E-8 stated that R-8 is friendly and lovey and that may be why he goes to her. There was no incident report done or documentation of this in the medical record. E-5, LPN, stated during an interview on 08/07/03 at 3:10 p.m. that the female resident is R-8 and "she can't defend self like the others." E-5 said that R-7 has exposed himself to various residents and "it happens enough that he needs some other medication."

E-1, the Administrator, stated during an interview on 08/07/03 at 10:30 a.m. that she did not know the extent of the problem. She also stated that R-8 is childlike, can be led, and loves attention. E-1 stated that most of the other women in the unit are more aggressive with the men and do not necessarily like them.

The medical records for R-8 and R-13 did not indicate any services provided to these residents to evaluate the effect of these incidents on them or any attempts by the facility to assure their safety. The facility neglected to make the needed changes after the 02/22/03 incident to protect the other residents in the locked Alzheimer's Unit from additional inappropriate sexual behavior and comments.

Analyzing warning signs of inappropriate behavior and tracking of when these behaviors occur has not been identified. When asked, E-1, E-2, and E-3 could not provide any evidence of consistent behavior tracking nor attempts to monitor R-7's location to prevent further incidents.

The most recent care plan for R-7 dated 05/29/03 does not include a problem of inappropriate sexual behaviors. The facility neglected to re-evaluate the care plan and implement appropriate behaviors.

No written investigations of the sexual inappropriate behaviors were done by the facility nor were these incidents reported to the Department.

Based on facility data and interviews, the facility failed to adequately develop and operationalize the facility policies on inappropriate resident to resident sexual behaviors through ongoing training of all employees in the facility on the abuse policies resulting in direct care staff not reporting allegations of inappropriate sexual behavior to supervisory staff. Staff did not recognize inappropriate sexual behavior, report the incidents, and investigate resident to resident inappropriate behavior regarding R-7's sexually inappropriate advances which resulted in seven incidents of sexual advances towards residents R-8, R- 13, and unknown, unidentified residents, from 02/22/03 to 07/20/03.

The findings include:

1. E-1, Administrator, stated during an interview on 08/08/03 that abuse training is done during the initial training process and through annual inservice training. The last inservice training was 09/04/02.

The abuse policy includes a section titled "Abuse - Resident to Resident Altercations". The interventions listed to prevent this type of abuse are as follows.

A. Behavior tracking for high risk residents and residents taking psychotropics.

B. Immediate follow up on complaints from residents in regard to another resident.

C. Explanation and written acknowledgment of responsibility regarding responding to resident to resident altercations.

This policy states that any disturbance between residents will be immediately reported to the supervisor, Administrator, and the Director of Nurses. The policy states that the Director of Nurses and the Administrator will evaluate the occurrence for necessity of transferring the resident to an appropriate facility. Public Health is to be notified within 24 hours of the occurrence and a full written report will be submitted within five business days.

2. There were only two behavior tracking sheets completed for R-7 even though there were seven incidents of inappropriate sexual behavior.

The following incidents were found in the nurses notes, the behavior tracking sheets, or during interviews with staff.

B. During an interview on 08/07/03 at 3:10 p.m., E-5, evening licensed practical nurse, stated that she received a report that R-7 was involved in a sexually inappropriate behavior with R-13. Both of these residents have Alzheimer's Disease and neither has the ability to engage in a consensual sexual relationship. E-5 stated that R-7 was found on his knees, pants down and his penis out of his pants over R-13. E-1, Administrator, and E-5 discussed this incident and decided it had occurred between the last week in February and the first week in April, 2003. There is no written documentation of this incident in the medical record, on an incident report or a behavior tracking sheet.

E. The nurses notes dated 06/09/03 at 12 a.m. for R-7 document, "CNA informed nurse that he had walked up to her and said, 'I would like to screw you.' She in turn stated 'You need to go and sit down.' He then proceeded to zip and unzip his pants. Explained to him that this was not acceptable behavior." There was no incident report and no behavior tracking sheet completed for this incident. The facility did not increase supervision nor did they implement interventions so that R-7 did not turn this behavior toward other residents.

F. The 06/19/03, 6 a.m. entry in the nurses notes state, "was seen standing next to another resident's bed with resident in bed- zipping up his pants. question of interaction?". There was no incident report and no behavior tracking sheet completed for this incident. No resident was identified.

3. E-5, LPN, stated during an interview on 08/07/03 that the certified nurses aides are to fill out the behavior sheets but she did not know what happened to them after that.

E-1 stated in an interview on 08/08/03 that the staff in the locked Alzheimer's unit had not received any additional training before starting to work in that unit. E-1 stated that when the unit opened several years ago, staff received training and those staff trained the new employees who work in the unit now. No additional training is given to the staff in the Alzheimer's unit on appropriate interventions to deal with aggressive residents.

E-1 stated in an interview on 08/07/03 that she had not been told of the behaviors that R-7 was exhibiting toward residents.

Staff did not identify, report, correct, and intervene to prevent the reoccurrence of R-7's inappropriate sexual behavior. R-7's care plan did not include inappropriate sexual behavior as a problem nor were there any interventions to stop these behaviors from occurring. The facility did not increase supervision of R-7 after these occurrences to ensure that all residents on the unit were free from the inappropriate sexual behaviors.

There was no consistent documentation found in the medical record or in the behavior tracking book to assure that the staff assigned have knowledge of R-7's care needs related to his behaviors.

Interviews with staff including E-5, LPN, E-8, CNA, E-1, Administrator, E-2, Director of Nurses, E-3, Assistant Administrator, indicated that they did not know about all the incidents of inappropriate sexual behavior by R-7 nor did they know the extent of this sexual aggressiveness.

This REQUIREMENT is not met as evidenced by:

Based on staff interviews and record review, the facility failed to develop an appropriate and effective behavior plan regarding the inappropriate sexual advances and behaviors of one male resident, R-7, with undesirable sexual behaviors towards one female resident R-8, one male resident R-13, and other unidentified residents in the locked Alzheimer’s Unit. These sexual advances and behaviors were occurring from 02/22/03 until 07/20/03.

The findings include:

1. R-7 is a 73-year-old resident in the locked Alzheimer's Unit who has been a resident in the facility since 12/11/00. R-7 has long and short term memory problems and is moderately impaired for daily decision making as documented by the most recent quarterly minimum data set dated 05/29/03. Based on observations and the quarterly minimum data set, R-7 ambulated independently and is not interviewable. His only diagnoses is Alzheimer's Disease.

The following incidents were found in the nurses notes, the behavior tracking sheets, or during interviews with staff.

B. During an interview on 08/07/03 at 3:10 p.m., E-5, evening licensed practical nurse, stated that she received a report that R- 7 was involved in a sexually inappropriate behavior with R-13. Both of these residents have Alzheimer's Disease and neither has the ability to engage in a consensual sexual relation. E-5 stated that R-7 was found on his knees, pants down and his penis out of his pants over R-13. E-1, Administrator, and E-5 discussed this incident and decided it had occurred between the last week in February and the first week in April, 2003. There is no written documentation of this incident in the medical record, on an incident report or a behavior tracking sheet.

E. The nurses notes dated 06/09/03 at 12 a.m. for R-7 document, "CNA informed nurse that he had walked up to her and said, 'I would like to screw you.' She in turn stated 'You need to go and sit down.' He then proceeded to zip and unzip his pants. Explained to him that this was not acceptable behavior." There was no incident report and no behavior tracking sheet completed for this incident. The facility did not increase supervision nor did they implement interventions so that R-7 did not turn this behavior toward other residents.

G. A behavior tracking sheet dated 07/20/03 documents that at approximately 1:30 p.m. the following took place in a resident room. "Res (resident) had his pants unzipped and was standing in front of a female res attempting to expose his penis. The female res was sitting down in a chair. R-7 was standing directly over the top of her, straddling her legs, ending up in the position where his perineal area was in female res face. R-7 was saying something to the female res when this CNA approached the room but the words were unclear and whispered." There was no incident report done or documentation of this in the medical record. The female resident was not identified.

E-5, LPN, stated during an interview on 08/07/03 at 3:10 p.m. that the female resident is R-8 and "she can't defend self like the others." E-5 said that R-7 has exposed himself to various residents and "it happens enough that he needs some other medication."

E-1, the Administrator, stated during an interview on 08/07/03 at 10:30 a.m. that she did not know the extent of the problem. She also stated that R-8 is childlike, can be lead, and loves attention. E-1 stated that most of the other women in the unit are more aggressive with the men and do not necessarily like them.

E-7, social service designee, stated during an interview on 08/07/03 at 9:30 a.m. that she has had this position for six months and was trained by the previous social service person for the first two weeks. E-7 also stated that she does not have a plan in place to manage R-7's behaviors or to assure that R-8, R-13, and other unidentified residents are safe from these inappropriate sexual behaviors. E-7 stated that the only incident she was made aware of by other staff was the 06/05/03 incident involving R- 8. During this interview, E-7 stated she did not talk to R-8 nor R-13 after these incidents.

According to review of R-7's record and verified through staff interviews, this ongoing pattern of resident to resident sexual behavior for 02/22/03 to 07/20/03 was not effectively pursued by social service staff or outside referrals.

Analyzing warning signs of inappropriate behavior and tracking of when these behaviors occur has not been identified. When asked, E-1, E-2, and E-3 could not provide any evidence of consistent behavior tracking. Of the eight incidents, only two were documented on behavior tracking sheets. There is no consistent documentation of these incidents.

The most recent care plan for R-7 dated 05/29/03 indicated problems of needing supervision due to his Alzheimer's Disease and has had a rash since 09/03/02. The care plan does not include a problem of inappropriate sexual behaviors even though there has been eight inappropriate sexual behaviors incidents since 02/22/03. No attempts were made to re-evaluate the care plan and implement appropriate behaviors until the surveyor brought this issue to E-1's attention.