Facility I.D. Number: 0039859
Date of Survey: 10/27/2003
Follow-up to July 2, 2003 Annual Certification
Incident Report Investigation of August 16, 2003,
Incident Report Investigation of October 7, 2003,
Incident Report Investigation of October 21, 2003
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 EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR. (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 RESIDENTS 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 interview and record verification, the facility has failed to assure a safe environment for residents of the facility (R1, R6) with the potential to impact all individuals residing in the facility (R2, R3, R4, R5, R7, R8, R9, R10, R11, R12) when:
Based on interview and record verification, the facility neglected to safeguard resident (R1) after being physically assaulted by another client (R13).
1) Per review of facility's Physician Order Sheet, R1 is a 54 year old male who functions at the moderate level of mental retardation.
Per Physician Order Sheet, R13 is a 35 year old male with diagnoses of mild mental retardation, Schizophrenia and Borderline Personality Disorder. Per facility's records, R13 was admitted to the facility on 10/30/02 from the county jail on burglary charges. According to a QMRP (Qualified Mental Retardation Professional) report dated 2/25/03, R13 was put on probation on 2/19/03 for 48 months and had been sentenced to 100 hours of community service after having entered a plea of guilty to the burglary charges.
Per review of the facility's investigative report dated 8/16/03, the report states that R4 alleged that R13 had covered R1's face with a pillow and punched him in the stomach. According to the report, staff "had heard R4 a couple of nights ago repeating the story". The report also indicated that this may have happened "on one occasion or possibly several". It went on to state that R13 confessed to hitting R1 in the stomach on 8/9/03, but denied putting the pillow over R1's face. R13 was subsequently escorted to the local county jail and discharged from the facility.
Per interview with R4 on 9/16/03 at 4:45 p.m., R4 said that R13 had gone into R1's room, "put a pillow over his head and hit him in the stomach". R4 also stated that R13 had tried to talk her into doing it with him but she refused. R4 told surveyor that she had told staff about it but doesn't remember "who all I told".
During interview with E4, DSP (Direct Service Person), on 10/21/03 at 1:40 p.m., E4 said she had been off work for two days and the incident must have happened that weekend. E4 stated that when she returned to the facility for her next shift, R1 told her someone had "clobbered" him. E4 explained that R1 says this a lot even when he runs into something so she didn't think too much of it.
Per continuing interview, E4 said that after R1 told E4 about someone "clobbering him", R4 told E4 that R1 had tried to get her (R4) and R13 in trouble, that R1 had told on them to the RSD. E4 stated that R4 then told her that R13 had gone into R1's room and he and R4 hit R1. E4 said that she didn't report any of this to the RSD for a couple of days because R4 had said that R1 had already told the RSD.
Per interview with E1, Residential Services Director (RSD), on 9/17/03 at 10:35 a.m., E1 confirmed that staff had not come to her with any allegations of abuse towards R1 by R13 until 8/14/03.
E1 confirmed that she had not began her investigation into the incident until 08/16/03, and that she had not finished questioning all staff about the incident until the next week. When surveyor asked why she had waited to initiate the investigation, E1 replied, E3 was out of town and I was waiting for him to get back and tell me what to do.
E1 continued to say that even though she had been informed of the incident on 8/14/03 and 8/15/03, both R1 and R13 attended the same day training site and rode the day training bus to and from the facility (approximately 38 miles one way).
Facility was unable to provide surveyors with evidence that they had completed a thorough investigation into the allegation of abuse.
E1 also verified that she had not notified the Illinois Department of Public Health until 8/16/03, after she had met with the acting administrator for guidance.