Regal Health and Rehabilitation Center
Facility I.D. Number: 0038091
9525 S. Mayfield Ave.
Oak Lawn, IL 60453
Date of Survey: 1/29/04
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
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
Departments 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 residents physician of any accident,
injury or significant change in a residents 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 facilitys 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 residents 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.
- 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 Alzheimers 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.
- 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
- 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 R1s 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 R1s bed with his penis in R1s 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.
- Interview of R2 on 01/21/04 confirmed above statements by E3.
- 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.
- Facilitys 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 residents physician will be
contacted for further instructions. If there is reasonable cause to suspect
mistreatment, the resident or residents 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.
- 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 residents 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
R1s 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.
- On 01/26/04 Z2, R1s 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
R1s legs are very rigid and she had already been bathed.
- On 01/26/04 Z3, R1s 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.
- 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.
- 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.
- 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
- 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.