Statement of Violation

Bement Health Care Center

Facility I.D. Number: 0046052
601 North Morgan
Bement, Illinois 61813

Date of Survey: 12/16/2003

Annual Licensure Survey

“A" VIOLATION(S):

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 supervise and oversee the nursing services, 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.

Developing an up-to-date resident care plan for each resident’s comprehensive assessment, individual needs and goals to be accomplished, physician orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident’s condition. The plan shall be reviewed at least every three months.

A FACILITY EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR.

A FACILITY ADMINISTRATOR WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER BY TELEPHONE AND IN WRITING TO THE RESIDENT’S REPRESENTATIVE.

A FACILITY ADMINISTRATOR, EMPLOYEE, OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL ALSO REPORT THE MATTER TO THE DEPARTMENT.

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.

These REQUIREMENTS are met as evidenced by:

Based on observation, interview and record review the facility failed to immediately report an allegation of inappropriate touching of a resident (R2) by one of two residents (R8) registered as a sex offender, resulting in a second incident of inappropriate touching of a resident (R20) by R8. The facility failed to ensure the protection of residents from further inappropriate touching, by the failure to report and investigate the allegation of inappropriate touching of the face and chest of R20, by the same registered

sex offender (R8). The facility failed to thoroughly investigate one of two allegations of inappropriate touching (R20), failing to ensure the protection of residents from the potential for further inappropriate touching by R8. The facility failed to notify the Department of Public Health, the physician or family, of two allegations of inappropriate touching by the same registered sex offender.

Findings include:

1.The admission face sheet confirms that R8 was admitted to facility on 6/6/03. Review of the physician

order sheet dated December 2003 confirms that R8 had diagnoses of Anxiety, Depression, Hypertension,

Congestive Heart Failure and Renal Insufficiency. The assessment dated 9/11/03 confirms that R8 has no

problems with long or short term memory and required limited assist of one for transfers, locomotion,

dressing, hygiene, bathing and toilet use. The Significant Change Assessment dated 12/4/03 confirms that

R8 continues to have no problems with long or short-term memory and is independent with transfers,

locomotion, dressing, hygiene, bathing and toilet use.

The care plan dated 12/4/03 confirms that R8 is on parole from a Correctional Center meets with his parole officer on a regular basis and is registered with the sheriff's department. The care plan states, "Exhibited unnatural fondness for children prior to incarceration." The care plan identified the following approaches: "Res is supervised per staff at all x's [times]"; "Res must call parole officer before he leaves the building for any outings"; "Make staff aware no children are to be allowed in resident's care"; "Listen to inappropriate comments r/t children"; "Notify M.D. and mental health if inappropriate behavior with children".

The current physician order sheet confirms that R2 has a diagnosis of Alzheimer's with Agitation. The assessment dated 11/5/03 confirms that R2 has long and short-term memory problems and requires total assist with transfers, dressing, eating, hygiene and bathing. The care plan dated as reviewed on 11/14/03 has the following approaches identified: "Redirect res when she reaches out for people in halls"; "If res cont to grab at staff and other res take to room"; "Family to provide undershirts for staff to put on res when dressed." There is an entry on the back of the care plan dated 12/10/03 stating, "Res cont to

grab at people when they walk by, will even pull self down halls using rails in halls and reach out for people who are near her. Res also will raise up shirt when in hallway et [and] pull pants up to knees."

E5, Certified Nurse Aide (CNA), confirmed in interview on 12/10/03 at 10:15 a.m. and 11:15 a.m. that about three weeks ago, he saw R8 in the television [TV] room touching R2 on the legs and arms, but R8 stopped when he saw E5. E5 stated that he moved R2 from the TV room and told E4, the nurse, what he had witnessed. E5 confirmed that when he brought R2 to the TV room, R8 was not in the room, but that R8 frequently would go to the TV room after dinner.

E4, Practical Nurse (LPN), confirmed in interview on 12/10/03 at 1:00 p.m. that about four weeks ago, E5 came to her and reported that he saw R8 try to "kiss" R2. E4 stated that she reported the incident to E10, RN (Registered Nurse) and then the next day also reported to E3, Care Plan Coordinator.

E5, CNA, was interviewed again on 12/10/03 at 1:00 p.m. regarding the incident he observed between R8 and R2. E5 confirmed that about four weeks ago he saw R8 "rubbing [R2's] thighs and arms". E5 confirmed that R2 was fully clothed at the time. E5 confirmed that R8 pulled back when E5 walked around the corner. E5 stated, "My suspicion, the way he pulled back was that [R8] was going to try to kiss her [R2]." E5 confirmed that when he put R2 into the TV room that she was in a wheelchair facing the TV and R8 was not in the room. E5 stated that when he came back into the room R2 was facing the wall with R8 sitting in a wheelchair perpendicular to R2's chair. E5 stated that he didn't think that R2 would be strong enough to move the wheelchair on the carpeting herself, and thought that R8 moved R2's wheelchair. E5, when asked what he thought about what he had witnessed, replied, "I thought it was inappropriate for him [R8] to do that to [R2], she wouldn't know what he was doing."

E10, RN, confirmed in interview on 12/9/03 at 1:45 p.m. that she had heard in report that E5 thought that R8 had kissed R2. E10 confirmed that she was not aware of R8 touching anybody else.

E1, Administrator and Abuse Coordinator, and E2, Director of Nurses (DON), confirmed in interview on 12/10/03 at 1:45 p.m. that they were unaware of the first incident witnessed by E5 and did not do an investigation. E1 stated that he thought the incident on 11/26/03 was with R2. E1 confirmed that he had not been in contact with Z1, Caseworker Placement Resource Unit.

E3, Care Plan Coordinator, confirmed in interview on 12/10/03 at 2:15 p.m. that no one told her anything, and that the first time she was aware of anything was when another incident was documented in R8's chart on 11/26/03.

E2, DON, confirmed in interview on 12/9/03 at 2:10 p.m. that the 15-minute checks for R8 started on 11/24/03 because someone saw R2 reach out to R8 when he passed by and he took her hand.

There is no documentation of the incident of inappropriate touching of R2 by R8 in the nurses notes for R2 or R8. There is no documentation in the nurses notes for R2 or R8 of the doctor being notified of the incident or of R2’s family being notified. The nurses notes for both residents were reviewed for the last year. The only documentation in R8's nurses notes relating to inappropriate touching is dated 11/26/03, which is another incident of R8 touching a resident inappropriately (R20).

2. The December 2003 physician order sheet confirms that R20 has a diagnosis of senile dementia with agitation. The Assessments dated 11/4/03 confirms that R20 has long and short-term memory problems, daily wandering which is not easily redirected, and requires limited assist with transfer, ambulation, dressing, toilet use and hygiene. The care plan dated as reviewed on 11/7/03 has the following approaches identified; "Redirect res during times when she will pull pants down et (and) take (incontinent brief) off" and "Encourage res to sit down during times of fatigue from walking too much."

R20 was observed at various times during the day on 12/9/03 and 12/10/03 wandering up and down the hallways. R20 was observed to try to exit the facility several times and also to open the door to the conference room entering the room several times.

The nurses notes in R8's record, dated 11/26/03 at 3:30 p.m. confirm the following information: "Resident [R8] was in TV room behind female resident [R20]. Staff came around corner and saw resident face pressed up against female resident. Lt. hand was on female part of female chest. Staff didn't see where Lt. hand was. Staff removed female from TV room and reported it to Director." There is nothing documented that R8's physician was notified of the incident. There is no documentation in R20's nurses notes of the incident, or that the physician or family was notified.

E9, CNA, confirmed in interview on 12/9/03 at 2:50 p.m. that she witnessed R8 on 11/26/03 around 3:30 p.m., put his arm around the shoulder of R20 with his hand on her chest and his cheek was pressed up against R20's cheek. When asked if R8 had his hand on R20's breast E9 said she wasn't sure. E9 confirmed that R20 was in a wheelchair in the TV room at the time of the incident. E9 stated that it looked like R20 was trying to come out of the TV room at the time and was grunting. E9 confirmed that grunting is how R20 communicates. E9 confirmed that she told the Administrator and the nurse what she witnessed. When E9 was questioned, if she was aware of R8 touching any other residents inappropriately, E9 stated that she thought he had been around R2, but had never seen R8 touch R2.

E1, Administrator and Abuse Coordinator, confirmed in interview on 12/9/03 at approximately 1:10 p.m., that he was aware of the incident identified in the nurses notes dated 11/26/03. E1 stated that he did an investigation and R2 was the resident involved in the incident of 11/26/03.

E1 interviewed R8 and confirmed that R8 denied touching any resident inappropriately. E1 confirmed that he talked to E2 (DON), E14 (Social Service), and E9 (CNA), as part of the investigation, but did not talk with anyone else. E1 confirmed that on the night of the incident he also notified the social worker from the county, who had been visiting R8 every week. E1 confirmed that he tried to reach R8's parole officer but couldn't remember when he tried to call him, but stated that E14 ended up calling the parole officer. E1 confirmed that R8's doctor was not notified of the incident. E1 stated that he told the staff to keep people who can't verbalize and who can't protect themselves away from R8 and they started doing 15-minute checks. E1 confirmed that there was no incident report filled out or written documentation of the investigation that he did.

The facility's "Social Progress Notes" dated 11/26/03 state, "It was reported to SSD [Social Service Director] that res was touching another (female) res in an inappropriate manner. Adm. called res counselor, left message for counselor to call back." The entry dated 11/28/03 states, "SSD called parole officer and left message. Parole officer returned call and talked to Care Plan Nurse [E3], she explained the incident."

E14, SSD, confirmed in interview on 12/9/03 at 1:20 p.m. that R8 was from the Department of Corrections (DOC) and had been a perfect resident until a couple of weeks ago. E14 stated that R8 inappropriately grabbed the front of a resident. E14 confirmed that the resident was either R2 or R20. E14 confirmed that she talked to the parole officer on 11/28/03, and that he visited R8 on 12/1/03. E14 stated that R8 was in DOC for a sexual offense and was still receiving sex offender classes from a counselor once a week.

E3, Care Plan Nurse, confirmed in interview on 12/10/03 at 2:15 p.m. that she talked to Z3, Parole Officer, on 1/28/03 and told him that R8 was touching a female resident and suggested that Z3 get R8 out of the facility.

R8 was interviewed on 12/10/03 at 11:45 a.m. about the allegations of inappropriate touching for R2 and R20. R8 denied doing anything but shaking hands with R20.

Z1, Caseworker Placement Resource Unit, confirmed in interview on 12/10/03 at 10:20 a.m. that she had been working with the Parole office for placement of R8 initially from DOC to the nursing home. Z1 stated that she thought R8's placement in the nursing home was appropriate because of the following reasons: R8's history of sexual offenses was pedophilia, he had no history of sexual abuse with adults; R8 was not very ambulatory which also lessened the threat; R8 had significant medical needs and he did not have mental health issues. Z1 stated that R8 was able to follow instructions, for instance if he was told not to do something, he would remember what he had been instructed not to do. Z1 confirmed that R8 was a registered sex offender and had a diagnosis of pedophilia.

Z1 confirmed that she first became aware of a problem on 12/1/03 when she received an e-mail from Z3, Parole Officer, stating, "[R8] had been caught twice getting somewhat handsey with the lower functioning residents." Z1 confirmed that after reading the e-mail on 12/2/03 she immediately began to try to find a more apropriate place for R8. Z1 was unable to find another placement for R8 so she confirmed that on 12/9/03 she started the process to revoke R8's parole. Z1 confirmed that the facility had not been in contact with her about the situation or made her aware that R8's condition had improved as documented by the significant assessment dated 12/4/03. Z1 stated that she still did not know exactly what happened with R8 at the facility.

Z3, Parole Officer, confirmed in interview on 12/11/03 at 11:30 a.m. that the facility called him a couple of weeks ago and informed him that R8 was getting "handsey" with some lower functioning female residents of the nursing home. Z3 confirmed that he contacted the Placement Unit, so they could start making arrangements for other placement. Z3 confirmed that he interviewed R8 about the allegations and R8 denied anything happening. When asked if in his opinion was R8 a potential threat to other residents, Z3 replied, "I think he became that threat. I think he's cycling into his sex offender status. "Z3 stated that his personal opinion is that every sex offender has the potential to reoffend. Z3 stated that he thought R8 should be labeled a "sexually dangerous person" and that basically he reoffended by doing what he did to the residents (R2, R20). When asked if in his opinion the facility should have called the police and reported the inappropriate touching to them, Z3 stated that the outcome in the end would be the same, R8 going back to prison, but that the police probably would have come and taken him to jail if they had called and reported the inappropriate touching of R2 and R20.

The December 2003 physician order sheet confirms that R20 has a diagnosis of senile dementia with agitation.

The assessments dated 11/4/03 confirms that R20 has long and short-term memory problems, daily wandering which is not easily redirected, and requires limited assist with transfer, ambulation, dressing, toilet use and hygiene.

The care plan dated as reviewed on 11/7/03 has the following approaches identified; "Redirect res during times when she will pull pants down et [and] take [incontinent brief] off" and "Encourage res to sit down during times of fatigue from walking too much."

The facility "Abuse Prevention Program" contains the following information:

a. "Residents who allegedly mistreated another resident will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety as well as the safety of other residents and employees of the facility."

b. "A written report shall be sent to the Department of Public Health. The written report shall contain the following information, if known at the time of the report:

Name, age, diagnosis, and mental status of the resident allegedly abused or neglected. Date, time, location and circumstances of the alleged incident. Steps the facility has taken to protect the resident."

c. "The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment and that an investigation is being conducted. The administrator or designee will inform the resident or resident's representative of the conclusions of the investigation."

d. The final investigative report will include the following: "Name, age, diagnosis, mental status of the resident allegedly abused or neglected"; "The Original Allegation"; "Facts determined during the process of the investigation, review of medical record and interview of witness"; "Conclusion of the investigation based on known facts"; “Attach a summary of all interviews conducted."