Regal Health and Rehabilitation Center

Facility I.D. Number: 0038091
9525 S. Mayfield Ave.
Oak Lawn, IL 60453

Date of Survey: 1/29/04

Complaint Investigation

“A” Violation:

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. These written policies shall be followed in operating the facility.

The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department. Notification shall be made by a phone call to the Regional Office within 24 hours of each serious incident or accident. If the facility is unable to contact the Regional Office, notification shall be made by a phone call to the Department’s toll-free complaint registry number.

The facility shall immediately contact local law enforcement authorities (e.g. telephoning 911 where available) in the following situations: Sexual abuse of a resident by a staff member, another resident or a visitor.

The facility shall notify the resident’s physician of any accident, injury or significant change in a resident’s condition that threatens the health, safety or welfare of a resident.

An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.

A facility administrator, employee or agent who becomes aware of abuse or neglect of a resident shall also report the matter to the Department.

These requirements are not met as evidenced by:

Based on review of the facility’s abuse policy, staff and other interviews and review of police report the facility failed to assure that an investigation of an alleged sexual assault is immediately and thoroughly investigated according to facility policy which includes initiation of an investigation upon learning of situation, informing local police authorities, informing the Illinois Department of Public Health (IDPH), informing the attending physician, informing the resident’s representative and seeking medical attention for the alleged victim (R1). The facility also failed to assure that staff have adequate knowledge of the abuse policy and ability to implement this policy. The facility failed to follow the Skilled and Intermediate Care Facilities Code 300.695 (77 Illinois Administrative Code 300) which states local law enforcement must be immediately notified of a sexual abuse by a staff member.

Findings include:

1. During interview on 01/21/04 E1, Administrator, stated that on 1/17/04 at approximately 8:30 a.m. he was called by E7, Licensed Practical Nurse, and was informed of an allegation of sexual abuse. The allegation was reported by E3, Nurses Aide, that she witnessed E2, Nurses Aide, sexually assault R1. R1 is a cognitively impaired resident and diagnoses include Alzheimer’s disease. E1 stated he then asked to speak to E2 and told him an allegation of abuse was made and he needed to punch out.
2. During interview on 01/22/04 E7 stated E3 had been late for work the morning of 01/17/04 because of an ice storm and arrived about 8 a.m. A little after 8 a.m. E3 came to her and stated I need to talk to you now. E7 and E3 went into medication room where E3 told her what she had witnessed. E7 stated E2 was in dining room when he received call from the administrator. E2 then came walking out of dining room and took the arm of E3 and went into a resident room (203). E3 then came back to E7 crying and stated E2 had cornered her in room 203. E7 then called E1 back who stated she needed to get a male staff and make sure E2 had left the building. E1 also requested that E3 write her statement. E7 stated E3 was very upset and eventually was able to write a statement. E3 then requested to go home and this was granted. E7 stated she examined R1 in the dining room and saw nothing around her mouth or on clothing of her upper chest. E7 was asked what facility abuse policy states should be done at the time of an allegation of sexual abuse against a resident. E7 could not state the policy or what is to be done in the case of an alleged sexual abuse. E7 was asked why R1 was not sent to the hospital and E7 stated she had examined R1 and found nothing. E7 did state she called E6, Assistant Director of Nurses. E7 then stated at that point the investigation was in the hands of Administration.
3. During interview on 01/22/04, E3 stated on 01/17/04 she arrived at work late (around 8 a.m.) because of an ice storm. When she went to second floor, she started to do rounds at her normal assignment of rooms 219 to 222. She saw the door to room 222 cracked and saw R1 in bed dressed and bed rails down. E3 stated R1’s rails are never down because of risk of falls and proceeded into the room without first knocking on the door. E3 stated she witnessed E2 at the head of R1’s bed with his penis in R1’s mouth. E3 stated when E2 realized she was in the room he backed away from the bed and turned away from her toward the wall. E3 stated she then left the room and went to speak to E5, Nurse Aide Team Leader. E3 asked E5 what she should do if she saw something wrong happen to a resident. E5 stated it must be reported. E3 stated she then told E7 who phoned Administrator. A short time later E2 was walking down the hallway, took her arm and took her into room 203. E3 stated E2 pinned her against the bathroom door and repeated over and over ‘I need this job, I would never do anything to hurt a resident.’ E3 stated she repeated over and over ‘I need to get out of here.’ E3 stated she was able to get out of room 203 after a resident (R2), who was in the room, asked if breakfast was on its way. E3 stated she was able to write a statement and asked to go home. She left the facility at approximately 9:30 a.m.
4. Interview of R2 on 01/21/04 confirmed above statements by E3.
5. Interview of E5 on 01/21/04 confirmed above statements by E3. When questioned regarding policy on abuse E5 stated he would report any questionable treatment of a resident, did not have real knowledge of protecting a crime scene but states a resident who is the victim of an alleged sexual assault should be sent to the hospital for examination.
6. Facility’s Abuse Prevention Policy states upon learning of a report of abuse the administrator or designee shall initiate an incident investigation. If harm is suspected, the resident’s physician will be contacted for further instructions. If there is reasonable cause to suspect mistreatment, the resident or resident’s representative will be immediately notified. The Department of Public Health will be immediately notified, and if off hours the hotline will be contacted. Within 24 hours a written report shall be sent to the Department of Public Health. Policy also states if there is possible sexual abuse do not shower, bathe or change clothes of the person attacked. If clothes have been changed, save the clothes for inspection. Contact the police. In cooperation with the police, have resident examined at the hospital and leave any bed linens in place; do not touch or move anything in that area of the alleged offense, pending further direction from involved law enforcement agencies.
7. Interviews, record review and incident report review revealed that facility did not initiate an investigation of this allegation of sexual abuse until 01/19/04, two days after allegation was made. Physician was not notified until 01/19/04. Z3, the resident’s representative was not notified until 01/19/04. Local police were not notified until 01/19/04. IDPH was not notified until 01/19/04. R1 was not sent to the hospital for an examination. None of R1’s clothing nor bed linens were left in place or saved for evidence for the police department. During an interview on 01/21/04, E1 was asked why R1 was not sent to the hospital for examination and E1 stated R1 was examined by E7 and there was no evidence anything happened. E1 stated that E2 was terminated on 01/20/04 because of unlawful restraint of another staff member.
8. On 01/26/04 Z2, R1’s attending physician was interviewed and stated she was not informed of incident until 01/19/04 in the afternoon or evening. If she had been notified on 01/17/04, she would have requested that R1 be examined at a hospital emergency room. Z2 stated she examined R1 on 01/21/04 but by that time R1 had been bathed, clothes were changed and it was now five days after an alleged sexual abuse. Z2 stated she attempted a gynecologist exam however R1’s legs are very rigid and she had already been bathed.
9. On 01/26/04 Z3, R1’s representative, stated she was not notified of incident until 01/19/04. Z3 stated E1 would inform her of the outcome of investigation but has not yet heard of results.
10. On 01/22/04 at 12:55 p.m. E8, Director of Nurses, was interviewed and stated she was informed of the incident on 01/17/04 by phone from E6, Assistant Director of Nurses. E3 was questioned as to abuse policy and what is to be done when an allegation of sexual abuse is made. E3 stated she did not know what the policy stated but she could find out. Surveyor read policy specifics as to what is to be done when an allegation of sexual abuse is made. E3 did not respond.
11. On 01/22/04 at 12:45 p.m. E6 was interviewed and stated she was called about incident on 01/17/04 at 12:30 p.m. by E7. E6 stated she phoned E8 to handle the situation. E6 did state she and E8 discussed R1 being sent to the hospital. E6 was questioned as to what policy states should be done if alleged sexual abuse is reported. E6 stated the Administrator is called and he directs the investigation. E6 could not state any specifics of procedures in case of alleged sexual abuse.
12. The facility failed to immediately contact local law enforcement authorities when an allegation of sexual abuse was made involving a staff member to a resident (R1). 77 Illinois Administrative Code 300.695 states the facility must immediately contact the local law enforcement for the above situation.
13. Police report dated 01/20/04 was obtained on 01/21/04 from Z4 which stated E2 was charged with one count of Aggravated Criminal Sexual Assault and one count of Unlawful Restraint. E2 appeared in bond court on 01/21/04.