| Lakeview Living Center Facility I.D. Number: 0028134 Date of Survey: 12/04/2003 Complaint Investigation "A" VIOLATION(S): AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Sections 2-107 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) 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) These regulations were not met as evidenced by the following: Based on review of incidents, record verification and interview the facility failed to provide supervision for R1, a client known to have sexually inappropriate behavior, at residential and day training sites resulting in R1 having non-consensual inappropriate sexual contact with 5 of 5 clients identified (R2, R3, R4, Z1 and Z2). 1) R1, per his face sheet is a 43 year old male whose diagnoses include Moderate Mental Retardation and Mood Disorder (Manic Features). Review of the facility's incident showed an 11/20/03 incident which was reported on 11/21/03 stating, "R2 reported to day training program B staff Z3, that last night while in bed peer R1 came in to his room and started to fondle him. R1 then instructed him to bend over and he then stuck his penis into his behind causing him pain and small amount of bleeding". Interview with E3, Director of Investigations on 11/21/03 at 2:22p.m. stated, "Staff persons are one on one for both R1 and R2 24 hours a day". E3 added, " R2 is at the Emergency Department for evaluation and R1 is still at day training program A". E3 was asked what was R1's supervision level prior to this incident, E3 stated, "R1 was closely monitored from 3:30p.m. to 10:00p.m. and from 10:00p.m. to 8:30a.m. he was on one on one monitoring ". E5, Residential Services Director (RSD) , was asked on 11/21/03 at 2:30p.m. what is close supervision, E5 answered, "the staff needs to know the whereabouts of the individual at all times". E5 added, "usually there are 5 staff on second shift and 3 staff on third shift". E5 was asked whose responsibility was it to monitor R1, E5 stated, "it is the responsibility of the direct care staff who had R1 in his/her team". E3 was asked if day training program A is aware of the incident, "Day training is aware of behaviors but not aware of this 11/20/03 incident." E5 added, "Inside day training R1 is closely monitored. If he uses the washroom they ensure that no one is in the washroom". E3 was asked why day training program A was not informed of the incident, E3 stated, "Typically we do but in this case I did not call day training because I was so busy and I just forgot". E5 added, "Day training already have protective measures in place. R1 is supervised by a job coach. They do not provide one on one monitoring at day training". A special Interdisciplinary Team Meeting dated 11/25/03 stated under summary of items reviewed, "one of one monitoring at residential environment (24 hours) with close monitoring at the vocational setting due to monitoring system at day training being in place". Z6 was interviewed on 11/26/03 a.m. via phone, Z6 stated, "On a given day, nobody specific is in charge of R1. My room is large as it is, our ratio is 1:9, and yes, it is possible that we won't be able to notice him leave". Z5 stated on 12/2/03, "I can't guarantee that he won't be able to slip away but our staff are always looking out for R1." R2 was interviewed on 11/25/03 at 2:05p.m. in his bedroom. R2 stated, "the boy upstairs, he raped me down there (pointing to his rectal area). He put his finger in my butt, he almost beat me up. He did it twice." R2 added, "Everybody was in bed he came to my room and he pulled my pants down and pulled my underwear down and he raped me. I fought him, he's tall, dark skinned , he's R1". 2) A review of R1's record at day training program A showed that on 8/7/03, while lunch hour is ending, R1 went to the restroom with another client. When staff walked in, R1 was about to penetrate Z1. Staff immediately redirected the behavior. On 8/14/03, an Interdisciplinary Team Staffing was held to discuss the supervision plan implemented by day training program staff due to sexually inappropriate incident at the day training program. This supervision plan includes R1 is never to go into the bathroom with anyone else at day training or any day training function without supervision from staff, R1 will not go on any outings without male staff and R1 will not go on any job sites with the street crew that day training staff can't guarantee supervision in the bathrooms and that any incidents involving R1 with his peers in a sexual nature will be reported to E3 on the day of the incident. Z5 stated, "On 8/14/03, the meeting was for the day training staff to change the supervision level and if I remember right, E3 told me that R1 was on one on one monitoring but it wasn't made clear to me that he was only one on one on certain shifts". E2, Qualified Mental Retardation Professional (QMRP) was interviewed on 11/25/03 in the conference room. E2 stated the following supervision levels for R1: June - 1:1 monitoring on 3rd shift only July - 1:1 monitoring on 3rd shift only August - 1:1 monitoring on 3rd shift only September - 1:1 monitoring on 3rd shift , close monitoring on 1st and 2nd shift September 9 - 1:1 monitoring 1st shift and close monitoring on 2nd and 3rd shift September 25 - 1:1 monitoring on 3rd shift and close monitoring on 1st and 2nd shift October - 1:1 monitoring 3rd shift and close monitoring 1st and 2nd shift November - 1:1 monitoring 3rd shift and close monitoring 1st and 2nd shift November 21 - 1:1 monitoring 24 hours a day E2 was interviewed if there were any changes in the supervision level after the 8/7/03 incident at day training, E2 stated, "August monitoring wasn't changed, it was still the same as July and June". E2 added "prior to this incident, referring to 11/20/03 incident, I don't think R1 was on any 1:1 monitoring for 24 hours". 3) Another incident of inappropriate sexual behavior at day training program A dated 10/24/03 was reviewed. The incident stated "that while exercising Z2 expressed to staff that R1 touched her on her bottom. This made her uncomfortable". 4) R4, a severely retarded male client was interviewed on 12/2/03 at the day training program A conference room. R4 was asked if R1 had touched him, R4 stated, "Yeah". R4 was then asked where R1 touched him, R4 answered, "penis", while standing up and pointing to his private area. R4 was then asked when R1 touched him whether it was during the morning or night, R4 stated, "Night". 5) R3, a mildly retarded male client was interviewed on 12/2/03 at the day training program A conference room. R3 was asked if R1 had touched him, R3 stated, "He used to touch me while I'm in the bathroom". R3 was then asked where R1 would touch him, R3 stated, "In between my butt and my legs and I told him to stop". R3 added, "he used to come to my room too". When asked how long ago this has happened, R3 stated, "a long time ago". R5, a mildly retarded male client was interviewed on 12/2/03 at the day training program A conference room. R5 was asked if R1 touched him, R5 stated, "No". R5 added, "R1 touched R3 in the privates in our room while we were sleeping about a couple of months ago". R5 was asked how he knew about R1 and R3 when he just stated that he was sleeping, R5 stated, R6 told me, he's our roommate". E6, the Program Supervisor of the 5th floor was interviewed on 12/2/03 at 12:50p.m.. E6 was asked if R3, R4, R5 and R6 are reliable reporters, E6 answered, "Yeah, they do tell the truth". (B). Based on review of incidents and interviews the facility failed to ensure that 1 of 1 incident of non-consensual inappropriate sexual behavior of R1 at day training program A on 8/7/03 was reported to Illinois Department of Public Health (IDPH) in accordance with State law. 5) R1, per his face sheet is a 43 year old male whose diagnoses include Moderate Mental Retardation and Mood Disorder (Manic Features). Review of R1's record at day training program A showed an incident of inappropriate sexual behavior. Per the incident of 8/7/03 at 12:35p.m., "lunch hour is ending, R1 went to the restroom with another client. When staff walked in, R1 was about to penetrate another client (Z1). Staff immediately redirected the behavior". On 11/26/03, the facility's reportable incidents for August were reviewed. Surveyor could not find the 8/7/03 incident of R1 and Z1. E1, Administrator stated on 11/26/03 at 11:10a.m. in the conference room, "the 8/7/03 incident was not reported by the day training staff as an incident but was reported to the facility as a behavioral report. No incident report was made". When asked if it was reported to IDPH, E1 replied, "Whatever you see in the reportable incidents folder for August is what we had reported". |