Moultrie County Community Center
Date of Survey: 1/9/03
Second follow-up to complaint investigation
An appropriate, effective and individualized program that manages residents behaviors shall be developed and implemented for residents with aggressive or self-abusive behavior. Adequate, properly trained and supervised staff shall be available to administer these programs.
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)
A FACILITY ADMINISTRATOR, EMPLOYEE, OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL ALSO REPORT THE MATTER TO THE DEPARTMENT. (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.
Based on observation, interview, and file verification, the facility neglected to protect individuals from abuse including non- consensual sexual interactions / sexual harassment and failed to prevent neglect due to lack of supervision for individuals with known special needs. The facility neglected to thoroughly investigate allegations of sexual abuse, neglected to report allegations of sexual abuse to the Administrator / Department, neglected to assess individuals for potential injuries related to allegations of sexual abuse, neglected to protect individuals from non-consensual sexual interactions, and neglected to revise behavior management programming as necessary due to inappropriate sexual behaviors for 2 individuals in the facility (R1, R5).
A. Per review of current physician's orders, R1 is a 20 year old male who was admitted to this facility in 11/02. The nursing notes, dated 11/14/02, and the Medical History, dated 9/12/02, state that R1's diagnoses include: Tourettes Syndrome, Pervasive Development Disorder, Obsessive Compulsive Disorder, and Schizo-Affective Disorder. Per review of R1's most recent psychotropic consent dated 12/9/02, R1 receives Seroquel, Haldol, Depakote, Imipramine and Zoloft. The consent states that the consequences of failing to take these medications include: physical aggression, violent outbursts, threatening behaviors, depression and property destruction.
Per review of facility incident reports, an incident report dated 11/19/02 states: R1 was talking to staff about magazines, and R1 stated to the staff member that "...he only liked sex magazines...". The report further states: R1 said "you know the ones with c- --- and b---- in it", and then continued to tell the staff member that R5 (R1's roommate) "tried to stick his you-know-what in him like he was going to hump him." The report stated that the staff member asked R1 if he had informed anyone about this, and he stated "no one answered". The report then states R1 was asked what he meant that no one answered, R1 then started saying that "R5 tries to make c-- come out of the end of his d--- . He puts this creamy stuff on it and makes it go up and down again...". Staff asked again if R1 spoke to anyone about this, and R1 said "...he hollered out but no one answered." The report states that R1 was then taken to speak with E1 and E2. The report further states that as R1 was walking to speak with E1(Resident Services Director - RSD) and E2 (Administrator), R1 continued to speak of this incident and stated "he does this everynight and that he is gonna move to another room and that R5 says if does not like it, don't look at it." The report then indicates this incident was reported to E1 and E2.
An incident report dated 12/3/02 states that R5 was heard saying that R1 "hit him in the testicles". The report states that when R1 was questioned regarding this incident, R1's response was, " I don't do it all the time." The report states when staff attempted to discuss this behavior with R1, R1 started making inappropriate sexual comments to the staff, threatened to punch the staff member in the stomach, tried to hit R5 in the testicles, and that he was going to kick the police officers a--. The report states that R1 stated if he was horny, he would f--- staff. The report further states after continued behaviors and attempts to leave the facility, the police were called and R1 was transported to the hospital.
An incident report dated 12/15/02 states that R1 was displaying behaviors of throwing chairs and slamming doors. R1 broke a dining room light when it was hit by a chair. The incident report also states R1 told R5 (remains R1's roommate) that he was going to "rape him while he slept".
B. Per review of current physician's orders, R5 is a 20 year old male with a diagnosis of mild mental retardation, Attention Deficit Disorder, Schizo-Affective Disorder and Impulse Control Disorder. The physician's orders indicate R5 takes Celexa, Depakote and Zyprexa for behaviors. Confirmed per interview with E1 on 12/30/02, that R1 and R5 remain roommates as of this date at 3:00 P.M.
Per review of facility incident reports, an incident report dated 12/11/02 states R5 was observed by staff with his hand near R3's buttocks as if he were going to "goose" R3. The report states staff intervened and informed R5 to leave R3 alone. The report states that R5 stated that "his roommate (R1) touched his private parts as did R3, R6, and R7...". The report further states: "Its sometimes a little hard to take R5 at his word because, according to him, someone is always touching him here or at workshop. However the one he accuses usually denies it (R3, R6). R1 doesn't deny."
Per interview with Z1 on 1/7/03 at 1:30 P.M., Z1 stated that he had been made aware of incidents between R1 and R5 by R5. Z1 further stated that R5 was no longer in the same room with R1. However he was concerned that R1 could hurt someone at the facility.
Per review of the documentation sheet for R5's problem-solving program, the notes state:
Per observations made on 12/30/02 at 1:00 P.M., R1 and R5 remain as roommates and confirmed per interview with E1. Per interview with E2 on 12/31/02 at 11:45 A.M., E2 stated that R1 and R5 are no longer roommates.
Per review of R1's behavior management plan dated 12/9/02, there is no specific objective in place to address R1's behaviors of inappropriate sexual touching or elopement. Per interview with E2 on 12/30/02 at 3:00 P.M., E2 stated that she felt these were new behaviors and would be baselined initially prior to programming. Per review of facility documentation, there is no evidence of baseline data obtained.
Additionally R5, per review of facility incident reports, has described incidents of inappropriate sexual interactions to R1 and R3. Per review of R5's behavior management program, there is no specific objective in place to address these behaviors.
Per review of facility records and confirmed per interview with E1 and E2 on 12/30/02 at 3:00 P.M., there has been no investigation into the allegations made by R1 regarding non-consensual incidents involving R5. Nor has their been any investigation into the allegation made by R5 regarding non-consensual sexual incidents involving R1, R3, R6, and R7. The interview with E1 and E2 on 12/30/02 at 3:00 P.M., confirms there has been no assessment by nursing staff regarding any potential injuries from the incidents described above. E1 and E2 confirm the Department was not notified of the stated allegations of sexual abuse, and no report has been completed by the Administrator until made aware by the surveyor. E1 and E2 confirm the behavior managment plans do not include specific interactions related to inappropriate sexual behaviors as indicated by the incident reports. E1 and E2 confirm there are no specific plans in place to ensure R1 and R5 are protected from non-consensual interactions with each other and other peers in the facility (R3, R6, and R7).
Based on interview and review of facility records, the facility failed to ensure all allegations of inappropriate non-consensual sexual interactions or abuse are reported immediately to the Administrator and to the Department affecting 2 individuals in the facility (R1, R5).
The facility failed to ensure all allegations of nonconsensual sexual interactions are reported to the Administrator and the Department.
Per review of current physician's orders, R1 is a 20 year old male who was admitted to this facility in 11/02. The nursing notes, dated 11/14/02, and the Medical History, dated 9/12/02, state R1's diagnoses include: Tourettes Syndrome, Pervasive Development Disorder, Obsessive Compulsive Disorder and Schizo-Affective Disorder. Per review of R1's most recent psychotropic consent dated 12/9/02, R1 receives Seroquel, Haldol, Depakote, Imipramine and Zoloft for behaviors including physical aggression, violent outbursts, threatening behaviors, depression and property destruction.
Per review of incident reports, these reports indicate allegations of inappropriate sexual touching were made by R1, accusing R5 of inappropriate non-consensual sexual interactions on 11/19/02. The facility incident reports also include 2 incidents in which R1's behaviors escalated requiring assistance by law enforcement after R1 left the facility without permission. These incident reports are dated 12/3/02 and 12/17/02.
An additional example is available for R5 who, per review of facility incident reports, has described incidents of inappropriate sexual interactions and touching by R1, R3, R6 and R7. These incident reports are dated 12/3/02, 12/11/02, and 12/12/02.
Per review of the facility incident reports and confirmed per interview with E2 (ADM) and E1 (RSD) on 12/20/02 at 3:00 P.M., it was confirmed these allegations of inappropriate non-consensual sexual interactions were not reported to the Administrator and the Department.