| HERITAGE MANOR-COLFAX Date of Survey: 12/20/02 Complaint Investigation “A" VIOLATION(S): 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; AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT 300.3240b) ABUSE OR NEGLECT A RESIDENT. 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. EMPLOYEE AS PERPETRATOR OF ABUSE WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT AN EMPLOYEE OF A LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT EMPLOYEE SHALL IMMEDIATELY BE BARRED FROM ANY FURTHER CONTACT WITH RESIDENTS OF THE FACILITY, PENDING THE OUTCOME OF ANY FURTHER INVESTIGATION, PROSECUTION OR DISCIPLINARY ACTION AGAINST THE EMPLOYEE These regulations are not met as evidenced by: Based on interview and record review facility administration failed to ensure the investigation and reporting of abuse in an objective manner by allowing a manager with a personal relationship to the perpetrator conduct the investigation. Facility administration failed to report to the IL Department of Public Health (IDPH) 3 of 3 allegations of sexual abuse (R3, R2); failed to make sure that staff had a clear understanding of the difference between the IDPH hotline and the Corporate Compliance hotline; failed to thoroughly investigate 1 of 3 allegations of sexual abuse (R3) and failed to investigate 2 of 3 allegations of sexual abuse (R2, R3). In addition facility administration failed to protect the residents from further incidents of sexual abuse from occurring by allowing the alleged perpetrator to continue to provide direct care to the residents which resulted in sexual abuse (R2,R3). Findings include: 1.) The December 2002 physician order sheet states that R3 has diagnoses of dementia, cerebral vascular accident and bipolar disorder with mania. The MDS(Minimum Data Set) dated 6/19/00 states that R3 has no short or long term memory problems, requires minimal assist with transfers and is not incontinent of bowel and bladder. Interview with E16, Licensed Practical Nurse(LPN) and former facility employee on 12/10/02 reports an incident of sexual abuse involving R3. E16 reports that in the fall of 2000 she was working as a Charge Nurse on the night shift with E14, a CNA ( Certified Nurse Aide). E16 and E14 were the only employees working on that shift. E16 heard R3 yelling "Help, Help" and went to R3's room and through a crack where the door was not completely closed, saw E14 CNA bent at the waist over the middle of the bed. The siderails on the bed were up. R3 was lying in the bed naked from the waist down, with her pajama top pulled up to her breasts with the sheets down at the foot of the bed. E16 stated she asked R3, "What's the matter?" R3 grabbed E16's hand saying, "My momma told me if anyone touches you down there like that, you are to holler for help until somebody comes". E16 stated that she asked E14 what he was doing and E14 responded that she(R3) was giving him a hard time. E16 then told E14 to leave the room. E16 stated that when E14 left the room R3's "demeanor relaxed". When E16 was asked if she had questioned R3 about whether E14 had touched her in the groin area E16 stated, "We did not further discuss the topic". E16 stated that R3's bedclothes were not wet and there was no clothing on the floor. E16 stated that she did not send E14 home, but allowed him to continue to work, as it was only the two of them working that night. E16 stayed over that morning and reported the incident to E13, the former Director of Nurses(DON) when she came into work. E13 was married to E14 at the time of this incident, and was responsible for conducting investigations of all allegations of abuse and neglect . E16 states that she didn’t hear from E13 for 3 days regarding her reported incident with R3, so she spoke with E1, the Administrator. E1 states, “ it is none of your business, we (E13 and E1;) did an in-house investigation and it was unfounded.” E16 stated that no one ever talked to her about the incident. E16 was the only witness. E16 was unable to remember the specific date that the incident occurred which was in the year 2000. E16 stated that she started a medical leave of absence on 12/10/00. Review of E14's personnel file states that E14 was hired on 8/10/00. The incident would have occurred between 8/10/00 and 12/10/00. E6 confirmed that two years ago R3 was alert/oriented, toileted herself and was not incontinent. 2.)E15 a CNA formerly employed by the facility described the following incident in interview on 12/6/02 at 1:05p.m.: E15 was working with E4 LPN and E14 the night the incident occurred. E15 was unable to remember the specific date the incident occurred but thought it was in May of 2001. E15 stated that she heard a scream, saw a head pop out of the doorway and heard another scream, ran down the hall and heard R3 yelling "Help, Help". R3 was lying naked on the bed, the upper half of the siderail was down. E14 was standing crouched over her(R3) head, with his zipper down. E15 asked him (E14), "What are you doing!" E14 answered “she's wet. “R3 kept saying, ?Help, Help, my momma said if anyone touched you there, then she would scream for help.’ She(R3) then pointed to her groin and said, “ he touched her down there.” E15 stated that E4 was right behind her and that E14 stepped to the side and kept saying "she was wet, she was wet". “I(E15) told him to get out of the room. (R3) was holding her groin saying ?Momma told me no one is to touch me down there’.” E15 stated that when she picked up the pads off the floor that they were dry. E15 said to E4, "Do you realize he was messing with her sexually". E15 stated that she left the room to get sheets to cover R3 with and continued to repeat to E4 about how he(E14) was messing with her(R3). E15 stated that R3 was frightened. E15 stated that she told E4 that she wasn't working with E14 anymore, so E4 assigned E14 and E15 to different resident halls. When questioned by the surveyor if she had reported the incident to anyone, E15 stated that she started to get concerned because nothing was going on, and reported the incident to E1, the Administrator. E15 stated that E1 told her there was an investigation going on, but that the "proper chain of command was for me (E15) to talk to [E13]", the former DON. E15 stated that she felt uncomfortable talking to E13 as she was his (E14) wife. E1 told E15 that she wasn't using the proper chain of command and told her to speak to E13, (DON) about it. E1 told E15 that there was an investigation going on and also told her to report it to a hotline number, and gave her the number. E15 stated that she thought that the number E1 was giving her was the IDPH (Illinois Department of Public Health) hotline number, when it was actually a corporate compliance hotline number. E15 states that she contacted the hotline number (corporate number) on 6/18/01 and reported that E14 was not able to care for 3 residents because he had touched them inappropriately. This call is corroborated by a copy of the corporate hotline report dated 6/18/01 documenting the above information. E15 returned a call to what she thought was the IDPH hotline on 6/25/01 requesting a response to her call on 6/18/01. She provided more information during this call releasing the name of one resident that she believed E14 was sexually abusing, and the names of other witnesses that could corroborate her statements. This call is also corroborated by a copy of the corporate hotline report dated 6/25/01. On 6/27/01 E15 met with E13 (former DON), E1 Administrator, E4 LPN, and E7 (Senior Vice President of Human Resource and Employee Relations). Interview with E7 on 12/11/02 at 10:10 a.m. reported the information that was discussed at that meeting. They discussed the information in regard to R3 and the alleged incident of sexual abuse by E14. During this meeting E1 denied that she knew anything about this incident and asked E4 at this time whether or not this incident occurred. E4 stated that she investigated it and determined that no abuse had occurred. According to E7 that was the extent of the discussion in relation to R3, the rest of the discussion related to E15's human resource related issues. During this interview E7 stated that she phoned E1, Administrator on 6/19/01 and made her aware of E15's corporate hotline call alleging that E14 was not to care for residents he had touched inappropriately. E7 stated that E1's response to her call was, "I don't know anything about (E14) not being able to care for any residents". E7 stated that she also had a phone conversation with E1, notifying her of R15's call to the corporate hotline on 6/25/01; wherein, E15 alleged that R3 had been sexually abused by E14. E7 stated that E1's response to that call, was that she had discussed the issue with E13 (DON) and that E13 said that there was "no problem with (E14)”. An investigation was never initiated by E1or E13 after having knowledge of R15's allegations. 3.)E4, LPN worked with E15 and E14 when the incident occurred in May 2001 and stated the following information in interview on 12/4/02 at 12:10 p.m.: R3 was yelling out so E4 sent E14 down to R3's room, E14 was unable to quiet her so she sent E15 down to check on her (R3). E4 stated that E15 was unable to quiet R3 so she(E4) went down to check on her. E4 stated that E15 told her that she thought something had gone on with E14 and R3. “I went down to (R3's) room and did a full body assessment, and asked (R3) if anyone had touched her inappropriately. (R3) did not answer me (E4)”. R3 had a nightgown on that was tied around her neck but R3 had flung the nightgown to the side and the covers were off. “I had (E15) take care of her for the rest of the night.” When asked what made her ask R3 if she had been touched inappropriately, E4 stated that she couldn't remember exactly what E15 had alleged. E4 could not remember when the incident occurred, but thought it might have been cold out. Review of a statement written and signed by E4 on 6/28/01 confirms the following information: "I[E4] 11-7 charge nurse at [the facility] witnessed an incident with resident [R3] where the res. began screaming "help" very loud in the middle of the noc on what date and exact time I do not remember. Upon arrival to the room [R3] was unclothed and CNA[E14] was assisting [R3]. [R3] stated "My mother taught me to scream if a man ever started doing something I don't like". This nurse interviewed took over care of [R3] calming and reassuring res. Then I directed CNA[E15] to continue care of res. I did not find [R3] allegations were founded, therefore I did not report this to my supervisor." A.) Review of the December 2002 physician order sheet states the diagnosis of senile dementia for R2. The MDS dated 7/16/01 states that R2 had long and short term memory problems with impaired decision making, totally continent of bowel and bladder, requires limited assist with dressing and was independent with transfers and ambulation. The care plan dated 7/16/01 states to assist with activities of daily living as needed; to provide verbal cueing and check for incontinence. 1.)E15 CNA stated the following information in interview on 12/6/02 at 1:05 p.m.: E15 stated she heard a noise and walked into R2's room, R2 was standing in the entrance to the bathroom with her pants down, with blood in her panties(underwear). R2 was naked except for her panties. R2 kept saying, "He was fretting with me". E15 asked R2 what is fretting with me. R2 said touching and said your down there, pointing to her groin area. E15 stated that E14 was shocked when she saw him as he was climbing out the bedroom window, E15 was able to see E14 when the bathroom light shone on him as the door was opened. E15 stated that R2 turned and looked at E14 when she (R2) was saying that he's fretting with me while E15 was talking to E14. E15 stated that she asked E14 what he was doing and that E14 did not answer her. E14 was fully dressed and was working that night with E15 and E5 RN(Registered Nurse). E15 reported the incident to E5 and said that E5 stated she would document the incident and talk to E14. E15 stated that E14 worked the rest of the shift that night. E15 reported the incident to E13, the former DON. E15 received a call from E13 the day after the incident about pay issues and asked if E15 had any care issues with E14, that there was an ongoing investigation. E15 recalled telling E13 that she was uncomfortable with this, because you (E13) are his (E14) wife. E15 stated that when she didn't hear anything about the incident, she called E1, Administrator and asked about the incident. E1 kept referring her back to E13 saying that E13 was a fair person. E15 could not recall the specific date of the incident but thought it occurred around the same time as the incident involving R3 and E14 which would have been in May 2001. 2.)E5 RN stated in interview on 12/11/02 at 1:55 p.m. that the incident with E14 and R2 did not happen while she was working, that no one said anything to her regarding abuse. 3.)E1 stated in interview on 12/3/02 at approximately 3:00 p.m. that she was not aware of any allegations of abuse other than the one involving R3 and E14. B.) During the start of this complaint investigation E1 was interviewed on 12/03/02 at 9:35 a.m. During this interview E1 was questioned regarding any staff to resident abuse allegations dating back to the year 2000. E1 denied that she had any knowledge, or documented incident investigations of staff to resident abuse from 2000 to present. E1 provided copies of all investigated allegations from 2000 to present. Review of these allegations on 12/03/02 did not include investigations of the above mentioned incidents involving R2 and R3, (three incidents total). These alleged incidents were never reported to Illinois Department of Public Health. In a later interview on 12/03/02 at 3:00 p.m E1 denied holding back an investigation and stated, "No one has made me aware of any allegation". E1 did report however, that she was aware of an incident involving R3 during an exit interview with E15 on 6/27/01. At that time E1 stated that she asked E4 if such an incident occurred as E15 was claiming. E4 stated that there was an incident where R3 was calling out and E14 and E15 were working, but stated she assessed R3 and questioned her, but came up with no determination of abuse; therefore, E1 stated that she was satisfied with E4's investigation and did not pursue an investigation of her own. E1 made the determination of no abuse by E4's verbal statement during the meeting on 6/27/01 and asked E4 to write out a statement. E1 did not interview R3, E15, or the alleged perpetrator E14. Review of E14's personnel file documents his employment as a CNA until 5/27/01 when he was transferred to a sister facility to continue CNA work. C.) E14 CNA (alleged perpetration) and E13 the former DON refused to talk with the surveyor on the advise of their lawyers. D.) The following interviews relate to E14's behavior and interactions with co-workers while he was working the nightshift:
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