| Burnham House Facility I.D. Number: 0041327 Date of Survey: 11-19-02 Incident Report Investigation of 11/3/02 “A" VIOLATION(S): The facility’s governing body shall exercise general direction of the facility, and shall establish the broad policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served. The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the administrator. The policies shall be available to the staff, residents and the public. These written policies shall be followed in operating the facility and shall be reviewed at least annually. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 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) These Regulations are not met. Based on observation, interview and record verification (including a review of facility Incident Investigation Reports), the facility has failed to:
a) the preservation of evidence. b) the immediate notification of Police. c) the rendering of immediate medical care (physical and psychological, as needed) to the victim by qualified professionals. 7. Ensure that a timely investigation of the sexual abuse to R1 on 11/3/02 contained reproducible evidence that staff were interviewed. Findings include: R1 is a 36 year old non-ambulatory but mobile man who has been diagnosed with Severe Mental Retardation, Cerebral Palsy, Spastic Diplegia, Visual and Hearing Impairments. According to R1's 2/1/02 Health Evaluation, R1 is non-verbal but communicates via gestures, sign language, a picture ID book/communication board, and an electronic communication device. R1 can stand and use a walker. R1 has resided at the facility for approximately 6 years. According to a facility's incident report dated 11/3/02 and a 11/4/02 Report of Possible Sexual Abuse, as well as surveyor interview of E2 on 11/8/02, an incident of sexual abuse occurred to R1 on 11/3/02 as follows: At approximately 5:15p.m. on Sunday, 11/3/02, Z1, a man not known to facility staff, came to the facility asking to visit with R1. Z1 claimed to know R1 from R1's previous placement. E2, the Hab-aide, did not recognize Z1 but took him back to see R1 who was in his bedroom. E2 stated that R1 acted like he knew and/or recognized Z1. E2 informed Z1 that she was about to shower R1. Z1 reportedly stated that he could shower R1. E2 informed Z1, "No, that's my job." Because E2 thought Z1's statement was odd, E2 left the room (leaving Z1 alone with R1) to call R1's guardian. E2 stated there was no answer so she then went to E3, another Hab-aide on duty, and asked if she had ever seen Z1 before. E3 said "No". When E2 returned to R1's bedroom, she did not see Z1 and R1 there. However, E2 did hear water running in the men's bathroom outside of R1's room. E2 stated she attempted to open the door to the bathroom and it was hard to open. E2 stated "it was like someone was holding the knob." When E2 successfully opened the door, she saw R1 sitting in his wheelchair naked. Z1 was standing in front of R1. E2 stated she saw "a white liquid substance" on R1's genital area and R1 had an erection. When Z1 saw E2, he picked up pajamas by the sink and covered R1's genital area with them. During the 11/8/02 interview, E2 stated that Z1 "looked nervous and was sweating bullets." E2 then observed the same white liquid substance on Z1's left arm. When E2 asked Z1 what was on R1, Z1 told her he didn't know. E2 then asked Z1 what was on his arm. Z1 told her R1 drooled on him and then wiped the substance off his arm. E2 stated she then told Z1 to leave the room. During the interview with E2 on 11/8/02, E2 stated that after Z1 left the bathroom, E2 showered and dressed R1. When asked why she showered R1, E2 stated: "I don't know. I guess I wasn't thinking." E2 continued relating the events of the evening of 11/3/02 stating that when she took R1 back to his bedroom, Z1 was present in the room. E2 stated E3 came to the bedroom area and stayed and observed Z1 and R1. E2 stated she tried calling the guardian again. According to the incident report, this call occurred at 5:50p.m. The guardian (Z2) informed E2 that she knew Z1 as a worker at R1's previous placement and that he would be able to visit. However, after E2 informed Z2 of what she had observed, Z2 said she would come immediately to the facility. E2 hung up with Z2 and went outside to obtain Z1's license plate number and car description. E2 stated that when she returned inside the facility, she paged E1, the RSD, and returned to R1's bedroom. She stated Z1 was acting nervous and put on his jacket to leave. According to the Incident Summary and the 11/8/02 interview with E2, E2 and E3 began questioning R1. E2 stated that R1 answered their questions and communicated with them through gestures and by nodding his head for "yes" and "no". R1 was able to relate that Z1 had taken him into the bathroom and removed his (R1's) clothes. R1 related that Z1 touched his (R1's) genitals and, by moving his hand up and down repeatedly, gestured "masturbation". R1 then stood and tried to sit on E2's lap, pointed to his buttocks and motioned his body in an up and down fashion, interpreted as meaning he was rectally penetrated. R1 then gestured that Z1 held his arm across his (R1's) throat. R1 gestured he tried to kick Z1. The incident report documents that E2 notified E4, the nurse-on-call, at 6:40p.m. The incident report, the facility Investigation Summary, and interviews with E2 on 11/8/02 and E3 on 11/12/02 all verify that E4 was informed of the incident by telephone. E4 was located in Springfield, IL and instructed E2 that "if R1 complains of pain or discomfort, take him to the hospital." At approximately 6:45p.m. on 11/3/02, Z2, the guardian of R1, arrived at the facility. E2 stated on interview 11/8/02 that she called the local Police after Z2 arrived, at approximately 6:46p.m. A review of the Police report indicates Police arrived at the facility at 6:51p.m. The guardian, Z2, questioned R1 with the Police present. R1 related to them what had happened to him with Z1; however, he omitted the part he related to E2 and E3 earlier about being rectally penetrated by not making any gestures to that effect. R1 was not sent to a hospital for assessment or treatment. E2 stated in 11/8/02 interview that although one of the two Policemen present said R1 should go the hospital Emergency Room, the guardian, Z2, didn't see any visible injury and didn't want him further traumatized. E1, the RSD, responded to her second page at 8:47p.m., per the incident report, and advised E2 to follow the instructions of the nurse and Police. Z2, the guardian, was interviewed by telephone on 11/12/02. Z2 was asked about her decision to not send R1 to the hospital Emergency Room on 11/3/02. Z2 was asked that if it had been explained to her how important it was for R1 to have gone to the hospital immediately, would she have made a different decision. Z2 stated: "Most definitely. " Z6, the Acting Administrator, was notified of the incident the next day, on Monday 11/4/02 at 10:30a.m., according to the incident report. E6 was interviewed on 11/12/02 at approximately 2:50p.m. E6 was asked if she had talked to R1's guardian, Z2, since the incident of 11/3/02. Z6 stated: "No." The incident report documents under the section "nursing follow-up": "Resident was examined by this nurse at Day Program when informed of incident. Resident was taken to exam room. Clothes from waist down removed. Groin area shows no sign of trauma; no redness, bruising or open areas noted. Anal area examined: no redness, swelling, bleeding or evidence of trauma noted." This nursing documentation was not dated or timed or signed as to when the exam occurred or when the note was written or by whom. E1, the RSD, informed surveyor the entry was completed by E5, the Nurse Consultant. E5 was interviewed on 11/8/02. E5 stated she was notified and completed the exam for R1 on 11/4/02 at 10 or 10:30a.m., approximately 16 to 17 hours after the sexual assault. E5 was asked why R1 did not receive medical attention and examination after the sexual assault on 11/3/02. E5 responded: "The nurse-on-call lives in Springfield; but the staff at the facility can go ahead and send a client to the hospital Emergency Room if they feel it's necessary." E5 was asked if she notified or consulted with the physician following her exam of R1 on 11/4/02. E5 stated: "No, I didn't call the physician. The house manager is the contact-person with the physician. I wouldn't know about the contact that they have made with the physician." According to the Incident Report and interview with E6, the Acting Administrator, on 11/12/02, the physician was not notified of the sexual assault to R1 on 11/3/02 until 11/7/02 at 11:40a.m. E6 stated that she came (from her office in Charleston, IL) to the facility to review the investigation in progress on 11/7/02 and identified that the physician had not been notified. It is noted that as of 11/13/02, 10 days after the sexual assault to R1 on 11/3/02, R1 has not been examined by a physician or received follow-up evaluations to rule out the possibility of his having obtained a sexually transmitted disease. E9, the Attending Physician for R1, was interviewed on 11/13/02. E9 was asked when he had been notified of the 11/3/02 sexual assault. E9 stated, "I believe it was Thursday, 11/7/02." E9 was asked if he had examined R1 or ordered lab work for R1 since the incident. E9 stated, "No, I didn't see the need since the nurse had examined him and saw nothing." The surveyor informed E9 of the details of the 11/3/02 sexual assault to R1 based on interviews with R1 and E2. E9 stated, "This is a different story than what I was told. Initially I was told that someone had come to the facility that was a mutual friend and that there was manual masturbation that was consensual, but that was all that happened." R1 was interviewed on 11/8/02 at the day program site with R1 using gestures, and his picture ID book. R1 was asked the following questions and gave the following answers: Do you know Z1? "Yes". Did Z1 come to your house? "Yes". Did Z1 take you to the shower-room? "Yes". Did Z1 undress you? "Yes". Did Z1 put you in the water? "No". Did Z1 touch your private parts? "Yes". Did Z1 masturbate you? "Yes". Did Z1 touch you anywhere else? "Yes", then R1 gestured to his buttocks. Did Z1 open his pants in the shower-room? "Yes". Did Z1 touch you with his penis? "Yes". Where did he touch you with his penis? R1 gestured to his buttocks. Then R1 gestured putting his arm across the surveyor's throat. Did Z1 put his arm across your throat? "Yes". Did you try calling for help? "Yes". Did anyone hear you? No response. Did staff come to the shower room? "Yes". Were you afraid? "Yes". Had Z1 ever done this to you before? "No", R1 began knocking on the table. Who was knocking, E2? "Yes". Was E2 knocking on the shower room door? "Yes". What was Z1 doing when E2 was knocking on the door? R1 wheeled to a door and put his foot by the door and gestured "masturbation". Did Z1 hurt you? "Yes", and R1 gestured kicking with his feet. Are you OK now? R1 pointed in his communication book to a picture of "Sad". Based on record verification and staff interview, the facility has failed to develop and implement written policies that would prohibit the mistreatment and sexual abuse that occurred to R1 on 11/3/02. Findings include: R1 is a 36 year old non-ambulatory, nonverbal man that communicates via sign language, gestures and communication book. His diagnosis is Severe Mental Retardation, Cerebral Palsy, Spastic Diplegia, Visual and Hearing Impairment. On 11/3/02 at approximately 5:15pm a visitor (Z1), came to the facility claiming to know R1 and asking to visit him. E2 (Hab Aide) did not know Z1, but let Z1 in. R1 appeared to know Z1. E2 informed Z1 that she was about to shower R1. Z1 stated he could do that. E2 informed Z1, "No, that's my job." E2 thought Z1's statement was odd. E2 left R1 alone with Z1 in R1's bedroom to go and attempt to call Z2 (R1's guardian) to ask about Z1. Z2 did not answer. Then E2 went to ask E3 (Hab Aide) if she had ever seen Z1 before. E3 stated she had never seen Z1 before and she had been employed there for 5 years. When E2 returned, R1 and Z1 were not in the bedroom. E2 found them in the bathroom. When she opened the door she observed R1 was naked and sitting in his wheelchair. R1 had an erection and there was a white liquid substance on his genitals. Z1 was standing in front of R1 with the same white liquid substance on his left arm. When E2 opened the door, Z1 tossed clothing that had been on the counter. on to R1's genital area. E2 asked Z1 what that was on R1. Z1 said he didn't know. E2 asked what was on Z1's arm. Z1 told her that R1 had drooled on him and wiped it away. E2 told Z1 to leave the room. E2 then proceeded to shower R1 and dress him in pajamas. E2 took R1 to his bedroom and Z1 was still there. E3 came into the hallway. E2 asked E3 to stay with R1 and Z1. E2 went to telephone the guardian (Z2) again. The incident report documents that this occurred at 5:40pm. Z2 was informed what E2 had observed. Z2 stated she would come to the facility immediately. E2 then paged the RSD (Residential Services Director). This page was verified as being received at 5:47pm by E1 (RSD). E1 was interviewed on 11/12/02 and stated that the page came in, but she had been unaware of this since the pager was on vibrator mode. E2 then went outside and got Z1's license plate number and car description. E2 returned to R1's bedroom. Z1 was putting on his jacket. The investigative report states Z1 appeared nervous and then left the facility. E4, the nurse on-call, was notified on 11/3/02 at 6:40pm. Per the incident report and interview with E2 on 11/8/02, staff were instructed,"If R1 is complaining, he should go to the hospital." R1 was never sent to the hospital on 11/3/02. According to the investigative summary, Z2 examined R1 and did not see signs of trauma and didn't feel R1 should be sent to the hospital. However, per 11/12/02 phone interview with Z2, Z2 said that she had not undressed R1 that night. She had questioned R1 and didn't see marks on his body that were showing outside the pajamas. Z2 was asked that if she had been fully informed of the importance, would she have sent R1 to the hospital the night of the sexual abuse. Z2 stated,"Most definitely." Local police were contacted at 6:49pm and arrived at the facility. The RSD was paged again at 8:45pm. The RSD instructed staff to follow the instructions of the nurse and the police. E6, the Administrator, was notified of the sexual abuse on 11/4/02 at 10:30 am. E5 (Nurse Consultant) examined R1 on 11/4/02 at 10 or 10:30am. This was approximately 16-17 hours after the sexual abuse occurred. E5 stated that she undressed R1 from the waist down, but did not see any signs of trauma. E5 stated she did not notify the attending physician of her exam. She stated that the House Manager usually does that. E9 (Attending Physician) was not notified of the sexual abuse to R1 until 11/7/02. E9 was interviewed on 11/13/02 per phone. E9 verified that he had not examined R1 nor had he ordered follow-up lab work to rule out the possibility of sexually transmitted diseases. Facts concerning the sexual abuse obtained by interview with E2 and R1 were discussed with E9. E9 stated," This is a different story than what I was told initially. I was told that someone had come to the facility that was a mutual friend and that there was manual masturbation that was consensual, but that was all that happened." The facility's policy on Reporting and Investigation Allegations of Abuse/Neglect/Psychological Sexual Abuse and the procedure to complete this investigation were reviewed. It states: "Upon receiving an allegation of abuse, neglect, mistreatment or psychological sexual abuse of an individual who lives in the home, the RSD will notify the following people, regardless of the quality or quantity of the information reported:
The Administrator will determine if the police need to be notified. If the police are notified, the RSD or Administrator will obtain a full report upon its completion. " E3 (Hab Aide) was interviewed on 11/12/02 at 4:50pm. E3 stated that she had been employed by the agency for 5 years. E3 was asked what she has been instructed by the facility when staff encounter crisis situations that need emergency services such as the police, ambulance etc. E3 was asked if hab staff are to call 911 immediately. E3 stated,"I think E1 (RSD) would trust us to go ahead and call 911 first, but we're not supposed to. The other two supervisors before E1 said we had to call them first. " Based on record verification and staff interview, the facility failed to provide evidence that the 11/3/02 allegation of sexual assault to R1 was thoroughly investigated. Findings include: R1 is a 36 year old non-ambulatory but mobile man who has been diagnosed with Severe Mental Retardation, Cerebral Palsy, Spastic Diplegia, Visual and Hearing Impairments. According to R1's 2/1/02 Health Evaluation, R1 is non-verbal but communicates via gestures, sign language, a picture ID book/communication board, and an electronic communication device. R1 can stand and use a walker. R1 has resided at the facility for approximately 6 years. Per the Facility Investigation Summary dated 11/4/02, on 11/3/02 at approximately 5:15pm a visitor (Z1) came to the facility and asked to visit with R1. The Hab-aide, E2, answered the door and took Z1 back to R1's bedroom. According to the summary, R1 appeared happy to see Z1. E2 informed Z1 that she was about to shower R1. Z1 told E2 that he would do R1's shower. Per the report, E2 told Z1 "No, that's my job." E2 left Z1 with R1 to call R1's guardian and to ask E3, Hab-aide, if she had ever seen Z1 before. E3 told E2 that she had never seen Z1 before. When E2 returned to the bedroom, R1 and Z1 were not in the bedroom. E2 went to the hall bathroom/shower room and when the door opened, E2 saw Z1 and R1 inside the room. E2 saw R1 had no clothes on. R1 had a white substance on his genital area. Z1 appeared to have a white substance on the front of his shirt. E2 asked what was on R1. Z1 responded that he did not know. The report goes on to state that E2 asked Z1 what was on his shirt. Z1 responded by saying R1 drooled on him and wiped the substance off. E2 asked Z1 to leave the bathroom. E2 then proceeded to give R1 a shower and put his pajamas on. The investigation summary states the guardian was called and came to the facility. It also states that E1, the Residential Service Director (RSD), was paged. The nurse was paged, and the local police were called. The Facility Investigation Summary states: "E2 notified the facility nurse and RSD of the incident. The nurse stated if R1 starts to complain of any pain or discomfort, "take him to the hospital." Under "Facility Action" of the Summary it states: "The facility nurse examined him also. She noted no marks, bruises, swelling, discolorations, or evidence of bleeding noted on his throat, penis or anal area....The Interdisciplinary Team (IDT) is also aware of R1's history of making false sexual allegations against others. These allegations usually occur when R1 is seen masturbating. R1 is aware that his mother does not approve of him masturbating. Fearing his mother will be notified, R1 has made false allegations on others so his mother will not be upset with him. The police will be responsible for further investigation." E1, the RSD, was interviewed on 11/8/02 per phone concerning the investigation of the 11/3/02 sexual assault incident. E1 was asked to provide the evidence she used to complete the investigation summary-- such as staff statements, interviews etc. E1 stated: "I have them with me. E8, the Assistant RSD, is pulling up my first notes that I sent to the computer now." E1 was asked when the nurse called. E1 stated, "the nurse on-call was notified that night." E1 was asked the nurse's name. E1 stated, "I don't know." E1 was asked if the on-call nurse came and examined R1 that night. E1 stated, "No. His mother examined him and said there was no injury. The nurse had said if R1 complained of pain to notify her." E1 was asked if R1's mother was a nurse. E1 said, "No." E1, the RSD, was re-interviewed on 11/12/02 at 11:50am. E1 was again requested to provide whatever reproducible evidence she had in regards to the 11/3/02 investigation of the sexual assault to R1. E1 provided the surveyor with 2 small pieces of paper that had writing on that was illegible. E1 stated these were her only notes from conversations from E2 and E3 (Hab- aides). E1 was asked if she had any staff statements or evidence of interviews for the following people and she stated: E2 (Hab-Aide)..... "I spoke to E2 that night. I told E2 to write in the Communication Book I had questions later about time frames and called E2 on 11/4/02 at 11am. I didn't tell her to come that day to write a statement. I don't remember if I gave her a date to provide a statement." When asked do you have a statement, E1 stated, "No." E3 (Hab-Aide)..... "I asked her to write a statement that Monday, 11/4/02. I ended up just verbally talking with her on 11/9/02. She agreed to just sign my notes on 11/9/02 because she agreed with the facts." E4 (Nurse-on-call)..... "I didn't even know who the nurse-on-call was for 11/3/02. I talked with E7, the Operations Manager on 11/8/02 to contact E5 (Nurse Consultant) to get the identity of the nurse so a statement can be done." E5 (Nurse Consultant)..... "She wrote her knowledge on the incident report. There has been no other contact concerning the incident like a statement or interview. On 11/8/02 E5 did say that E4, the nurse-on-call, disagreed with what E2 had written on the Incident Report regarding E4's verbal instructions to staff ." E9 (Attending Physician)....."No, I don't have an interview or statement. When E7 (Operations Manager) came to the facility on 11/7/02, E7 said we should have notified the physician." Z2 (Guardian of R1)..... "I called her several times discussing the incident." When asked if she had documented her interviews, E1 stated, "No." When asked did you know when Z2 examined R1 that he was dressed, E1 stated, "No, I didn't. I just assumed he was undressed." R1 ..... "I did interview R1 on 11/4/02." When asked for the notes from her interview, E1 stated, "I put the notes in my computer." During the 11/12/02 interview, E1 was asked if she, as the RSD, was the person responsible for conducting and gathering evidence for the investigation. E1 stated, "Yes, then I inform the Administrator." E1 was asked if she completed initial incident investigation summaries before getting staff statements. E1 stated, "Sometimes." E6, the Acting Administrator, was interviewed on 11/12/02 at 2:50pm concerning the incident investigation process for the 11/3/02 incident. E6 stated, "I came to the facility on Thursday, 11/7/02, to review the incident. I had been in contact with E1 between 11/4/02 and 11/7/02. I had asked E1 if statements were being obtained. I read what E1 had (the summary). I was told she had verbal statements. I told her to get a follow-up nursing assessment and get written statements. E1 said she was in the process of getting written statements." E7, the Operations Manager, was interviewed on 11/12/02 at 10:30am. E7 stated, "We were waiting for E1 to complete these forms (Agency Investigation Statement forms). Until this is completed our investigation is still open." |