CAROLE LANE TERRACE Facility I.D. Number 0035162 Date of Survey: 10/15/02 Complaint Investigation “A" VIOLATION(S): 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 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. (Seciton 3-610 of the Act) 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. (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) 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. (Section 3-611 of the Act) Review of an Incident Report Telephoned to Regional Office on 9/24/02 identifies an allegation of physical abuse to R1, which initially was reported as occurring on 8/19/02, but on further review reportedly occurred on 8/26/02. R1 is a 29 year old female with a diagnosis of Severe Mental Retardation. According to the report sent to IDPH dated 9/24/02, an investigation was “currently being held” regarding an alleged physical and verbal abuse incident toward R1. E4 witnessed R1's hair being pulled by E5 who then forced R1 into her bedroom stating R1 had to change her sheets because she had urinated on them. E4, who reported the abuse to E1 on 9/16/02, stated it happened 8/19/02, and failed to report the incident immediately per policy and procedure5.24. The policy reads: “Any facility employee or agent who witnesses or suspects a violation of resident rights, abuse, or neglect shall immediately report the matter to facility management.” The 9/24/02 report stated 1) the facility was conducting a thorough investigation insuring other individuals were not susceptible to other abuse of any kind; 2) R1 was taken to the emergency room (ER) for exam and her guardian was notified of the alleged incident; 3) the alleged staff member, E5, was suspended from duty until completion of the investigation; 4) disciplinary action would follow if found necessary. While the report appears to address the safety of R1 and the other 14 individuals of the home, interview with staff indicated the allegation of abuse was made known on 9/16/02. The facility failed to promptly initiate the abuse investigation and take action to protect residents from possible further abuse on that date. During an interview with E1, Residential Services Director, Qualified Mental Retardation Professional, (RSD, QMRP) on 10/03/02, E1 stated she became aware of the alleged incident of abuse to R1 on 9/16/02 from E4, part-time Team Leader, near the end of her 6:00a.m.- 2:30p.m. shift. E1 told E4 she would need to write a statement regarding what she had observed. E1 stated she told E2, the Assistant Administrator, of the incident around 9/19/02. E1 received a written dated statement of 9/18/02 from E4. E1 said in interview on 10/3/02 that she had completed the interviews with staff that were on duty on 8/19/02, E4, E5, and E7. She also interviewed individuals who were interviewable, R2, R3, R4 and R5. She also had attempted to interview R1. E1 said all interviews had been taped. She said the Investigative Committee attempted to meet on 9/27/02 however, all documents were not available for review at that time. The Committee reconvened on 9/30/02 finding no abuse substantiated. E2, Assistant Administrator, was interviewed at 8:40a.m. on 10/4/02. She stated she initially became aware of the 9/16/02 allegation of physical abuse on 9/19/02. E2 stated E1 spoke to her on 9/19/02 and E2 told E1 it was an allegation of abuse and a written statement was needed by E4. E2 states she thought E1 knew to report the incident to IDPH and the guardian immediately, as E1 has been employed by the agency a number of years. E2 did not become aware that E1 failed to report the incident to IDPH until 9/23/02 when E2 requested that E1 fax a copy of the notification. Interview of R1's guardian, Z1, occurred on 10/3/02 at 8:30p.m. via telephone. Z1 stated the facility had called him about a week and a half ago. E1, Residential Services Director, Qualified Mental Retardation Professional (RSD, QMRP), told him an allegation of abuse to R1 was being investigated. Z1 told E1 he hoped the staff being investigated would not be working with R1 if it was true she was abusing clients. Z1 stated E1 said she could not guarantee E5 would not be working with R1. Review of the facility’s Incident Report Telephone to the Regional Office reflects that although E1 was notified of the incident in 9/16/02 R1's family/guardian was not notified of the allegation of abuse until 9/20/02 at 8:40p.m. During an interview of E1, RSD/QMRP pm 10/3/02 at 1:15p.m. E1 stated she was told of the allegation on 9/16/02. When asked how she insured the safety of R1 and the other 14 individuals of the home after the allegation of abuse was known, E1 stated after the investigation began E5 was placed on suspension from work until the investigation concluded on 9/30/02. Verification and review of E5's punch cards showed a contradiction from E1's interview. From 9/16/02, the date the allegation was made, E5 worked alone on the 11:30p.m. to 9:30a.m. shift on 9/16/02, 9/17/02, 9/21/02 and 9/22/02. Suspension days were marked on the calendar for 9/25/02, 9/26/02 and 9/27/02. E5 was allowed to work unsupervised on 9/16/02, 9/17/02, 9/21/02 and 9/22/02 even though an allegation of abuse by E5 was made on 9/16/02. The facility did not insure the safety of R1 or the other 14 individuals of the home (R2-R15) once the allegation of abuse was made until the conclusion of the investigation on 9/30/02. |