TAYLORVILLE CARE CENTER
Facility I.D. Number 0028787
Date of Survey:08/28/02
Notice of Violation:11/26/02
Incident Report Investigation
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each residents comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
The DON shall oversee the nursing services of the facility including:
1) Overseeing the comprehensive assessment of the residents needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
2) Planning an up-to-date resident care plan for each resident based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
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.
These requirements are not met as evidenced by:
Based on incident report reviews, record reviews and interviews the facility neglected to provide for the safety of 11 female residents (R2, R3, R4, R5, R7, R8, R9, R10, R11, R12, R13) and 1 identified male resident (R6) when 1 male residents (R1), sexually inappropriate behaviors, aggressive behaviors and wandering into resident rooms behaviors, were not evaluated. The facility failed to implement appropriate and effective interventions regarding R1's behaviors from 4-11-01 to 7-30-02.
1) R1 is a 96 year old male admitted to the facility on 1-23-01. According to R1's Physician Orders Sheet, dated 8-1-02 to 8-31-02, R1's diagnoses include: Atypical Psychosis, Hypertension, Renal Failure, Syncope, Constipation, Anemia, History of Bilateral Pneumonia and Alzheimer's Disease.
A review of facility incident reports for the period of May 2002 through July 2002 indicate that incidents of R1's inappropriate sexual, aggressive and wandering into 2 resident rooms behaviors were not investigated as incidents until the incidents of 7-29-02 and 7-30-02 which were partially investigated. According to the 7-29-02 and 7-30-02 incidents:
a. On 7-29-02, "4 ladies sitting at nurses station (residents) R1 pulled down pants, nurses asked him to pull pants back up and said resident redirected to R1's room, reoriented to walker into wheelchair without provocation. R1 attempted to fondle a male resident's leg by rubbing his hand up legs. Resident was redirected and reminded that he had a snack waiting for R1."
b. On 7-30-02, "Went to resident's room (female) and closed door, was followed by CNAs when asked to leave area for own room, stated, 'I just want to make you feel good.' Resident in room peeking around door, masturbating, gesturing to others to come into room. Resident reoriented to place, time, Hospice informed, family informed. Physician informed. (Local hospital) emergency room informed of possible psych eval for R1 pending POA's permission."
According to the facility's Nurses Notes: On 7-28-02, the physician was notified of R1's recent
behaviors. On 7-29-02, the physician was notified for a psychological evaluation and Hospice was notified for re-evaluation with orders received on 7-29-02 at 1600 for medication.
On 7-30-02 continued behaviors of exposing self, masturbating, kissing female resident, gesturing to family member during masturbation and physician and Hospice notified followed by an order to send R1 to a local hospital emergency room for psychological evaluation due to inappropriate sexual behaviors. Family was notified. On 7-30-02, R1 returned and physician ordered, "Celexa 20mg 1 po (by mouth) daily" and "Medroxyprogesterone Acetate 150mg IM (injection) x (times) 1." On 7-31-02, R1 continued inappropriate behaviors, physician and family were notified, the physician ordered Medroxyprogesterone Acetate Injection was administered. R1 was sent to another local hospital for further psychological evaluation. R1 was permanently discharged from facility on 8-9-02.
Further record review indicates that R1 was ordered a psychological evaluation on 3-13-01. This was done on 3-22-01. No other evaluations were done until the incidents of 7-29-02 and 7-30- 02. This was confirmed with E1 (Administrator).
According to review of R1's record and verified through staff interview, this ongoing pattern of resident to resident sexually inappropriate, aggressive and wandering into residents room behavior from 4/11/02 to 7/30/02 was not effectively pursued by social service staff or outside referrals.
a. On approximately 12 occasions, R1 was observed, in general, touching, rubbing and fondling female residents' breasts, arms, heads, backs, face, shoulder and legs. Also, R1 was observed on 3 other occasions hugging and kissing female residents.
b. On approximately 12 occasions, R1 was observed rubbing R1's hands on female resident's breast and thighs. R1 stated, one occasion, "That was thrill of the day."
c. On one occasion, R1 licked the face of a female resident, rubbed resident's breast, placed hand on resident's thigh and stated, "You want it as much as I do."
d. On two occasions, R1 was rubbing female resident(s) between legs. On one occasion, R1 stated, "Oh she likes it and you would too if you gave it a chance."
e. On approximately six occasions R1 touched and/or grabbed female staff breasts, buttocks and
thighs. On two occasions, R1 stated, "Likes his women to look good" and "I'm going to undress you." Also, on one other occasion, R1 twisted the arm of Hospice CNA (Certified Nursing Assistant). On two additional occasions, R1 exposed penis at staff. On 1 occasion R1 slapped CNA's upper arm.
f. On three occasions, R1 was kissing and placing hands between female thighs, rubbing resident's thighs and placing hands up female resident's clothing.
g. On two occasions, R1 masturbated in living room with other residents present.
h. On four occasions, R1 masturbated, with exposure, in doorway of room. On one of these occasions, R1 motioned to a family member to come to him while he masturbated. On two other occasions, R1 masturbated in room with shades up, door cracked and peeked out door while masturbating. On another occasion, R1 masturbated at open window in room while looking out of window.
i. On one occasion, R1 removed clothing and stood naked in front of R1's open window. The window has a view to the street and public area.
j. On the following occasions, R1 wandered into other resident's rooms:
10-8-01 - sat in female resident's chair
11-13-01 - rubbed female resident's breast
11-13-01 - rubbed crotch of female resident
6-20-02 - in and out of all resident rooms
6-24-02 - pulled pants down in front of female resident
6-24-02 - rubbed hand up and down female resident's leg
6-29-02 - in and out of resident rooms
7-21-02 - in and out of resident rooms
7-27-02 - masturbated in a female resident's room while attempting to touch female resident's breasts
7-29-02 - wandering in rooms and touching female residents
k. On one occasion, R1 stood in front of a female resident and said Put your hand in here (inside zipper).
l. On two occasions, R1 remarked to visitors, on 10-21-01 and 12-2-01, Stated pat buttocks.
m. On one occasion, R1 was walking up and down halls with pants unzipped and genital exposed to residents.
n. On one occasion, R1 pushed residents out of R1's way.
o. On 7-21-02, at 1000, "Out in LR (living room). With walker resident deliberately running into other residents sitting in w/c (wheelchair)."
2) R1's Care Plan, dated 4-26-01 with last notation dated 6-18-02 in which goals were not met, states, "Resident make sexual comments/advances to staff and female residents: 1. tries to touch other females breasts, genital area 2. "let's get it on" "I know you'd like it.". Goals: Resident will reduce sexual comments/advances to 0 x's (times) for 30 consecutive days. R1's care plan, dated 4-26-01, has the following interventions/approaches:
The care plan also indicates the following notations: "12-7-? throwing walker on the floor (turning it over) reminded of danger - cont (continue) until something 01 else catches his attention." And, "Resident attempts to leave facility without assist of staff or family. Wanders throughout facility."
R1's pattern of inappropriate behaviors from 4-11-01 to 7-30-02 evidence the care plan approaches were not effective. The facility has neglected to evaluate the appropriateness of R1's care plan and make adjustments when approaches are not working.
3) During interviews with staff and residents the following was obtained:
a. Resident interview with R2, on 8-19-02, R2 indicated that R1 displayed inappropriate behaviors "a lot" and that R1 put R1's arm around R2. R2 also indicated that R1display inappropriate sexual behaviors to R4 three or four times before R2 could find "someone to help". R2 further indicated that facility needed "someone in dining room and watch people" and that R2 had to call for staff's assistance as R1 was at times unsupervised.
b. Staff interview with E7 (Certified Nursing Assistant), on 8-20-02, E7 confirmed that E7 had observed R1 touching residents, especially confused residents, and that staff had to respond to resident(s) calling for assistance with R1. E7 stated, "R1 wasn't real cooperative. Couldn't redirect his behavior too easily. R1 might stop for a minute and go right back. I've seen him touch residents. He would raise his walker up. I've never seen him threaten anybody. He could of hit somebody. R1 would touch residents breast and we told him to stop. Most women too confused to stop R1. Confused ones R1 would get ahold of." E7 further confirmed that staff were called to the living room to stop R1's behavior toward other residents.
c. Staff interview with E8 (Certified Nursing Assistant) on 8-20-02, E8 confirmed that E8 had observed, for 6 months or longer, R1 touching residents and staff, entering resident rooms, and that other staff, family and residents had to find staff members to assist/stop R1's behaviors. E8 stated, "We have had numerous occasions someone has had to come and get us with R1, being aggressive. We've had family, residents and other staff get us to stop R1."
d. Staff interview with E4 (Activities Director) on 8-19-02, E4 indicated that R1 touched confused residents, required redirection and that there may have been times when residents had to yell for help to redirect R1's behaviors.
e. Staff interview with E9 (Licensed Practical Nurse) on 8-20-02, E9 indicated that R1 touched "women's breast. MD was here one day and saw R1's behavior. He tried to touch me and I told him to stop."
f. Staff interview with E5 (Licensed Practical Nurse) on 8-19-02, E5 confirmed R1 was in female resident's rooms, expose self and masturbated.
g. Resident interview with R3 on 8-20-02, R3 indicated that R1 placed R1's hands on R3's knee while in dining room with husband.
h. Staff interview with E10 (Social Services Director) on 8-20-02, E10 indicated that E10 was told that R1 went into female rooms and masturbated.
i. Resident interview with R6 on 8-19-02 produced the following information:
R6 stated to surveyor. "He (R1) was going to hit me over the head with his walker, I took his walker away from him, he quit bothering me after I took his walker away from him." "My wife was here with me, she went to get help from the staff, there was not any staff around when he tried to hit me with the walker." " I think this happened about 2 or 3 weeks ago, I know he is not here anymore."
R6 stated. "I did not report it because my wife went to tell the staff, so I figured that they would tell whoever needed to know about it."
R6 denied that R1 had ever tried to touch him or anyone else, and stated to surveyor. "That was the first time he has ever tried to hit me, he wandered in my room all the time, I think because we shared the same bathroom." "He would come in my room and shut all the light switches off, and my computer, my TV, and all my power would go off, and I need power to operate my recliner chair I sit in, so I put duct tape over the light switches so he could not turn them off on me."
Interviews with the facility staff and record review indicates that R6 is interviewable. Additional Information for R6 example:
Interview with Z1 on 8-22-02 indicated the following. Z1 stated to surveyor. "He (R1) was going to hit my husband (R6) over the head with his (R1) walker, I went to get help at the nurses' station." "I don't remember who I told, but I recall that E1 was sitting at the desk at the nurses' station when I told the nurse at the desk." "I told the young girl in activities about R1 trying to hit my husband with the walker, she does not work here any more, she came into the TV room where my husband was sitting when R1 tried to hit him with the walker, but my husband had already taken the walker away from R1 when she got to the TV room." "This happened about 2-3 weeks ago right before he left here."
Z1 stated. "I had an incident with him myself." "He (R1) came up real close to me, leaning over me from the back, and said to me." "What kind of blouse do you have on.?" "Have you got anything in there?" "He (R1) grabbed our oldest daughter when she visiting here some time ago."
Z1 did state. "We did report both of those incidents to the administrator (E1)." Z1 also stated to surveyor. "I know about one incident with R5, she told me about it, she said she had to holler for help from the staff, she told me she was very scared of him (R1)."
R6 was present during interview with Z1 and stated to surveyor. "That is what happened he(R1) raised up the walker, and he was going to hit me with it, I took it away from him, so he just walked away after that."
R6 also stated to surveyor. "I told them in the care plan meeting ,that if he (R1) ever tried looking down my wife's blouse again, or if he tried grabbing my daughter again I would file charges against him."
Interview with E1 on 8-22-02 produced the following information.."I remember the incident of R1 raising his walker up, and R6's wife did report the incident to us, but R1 had a habit of picking up his walker over his (R1's) head, I don't know if he would have hit R6."
E1 also stated. " I do recall the incident of R1 making the comment to R6's wife, and that R6 did tell us in the care plan meeting, if that kind of thing happened again, he was going to file charges."
j) Interviews with residents R5, R7, and R8 on 8-19-02 and 8-20-02 produced the following information
1) R5 stated to surveyor. "He(R1) would try to grab me, I would tell him to go away, and he usually would, but about a month ago, he came into my room through the bathroom in my room, and I was starting to go into my room from the hallway, he was trying to grab me and shut my door."" He said to me." "You are a nice lady, want a feel?" "I called the nurse for help, they came and took him away." "He has tried to grab me several times, I just tell him to go away, but that day he just would not go away."
"I have seen him try to grab another lady in the dining room, but I don't know her name."
"I was afraid of him, I'm glad he is not here any more." "I would just stay away from him."
"I did not report it to anyone, I thought the nurse who came and took him away would report it."
Review of R1's records did not produce any documentation of the above incident.R5 also stated to surveyor. " I was sitting at the nurses' desk when he pulled his pants down, 3 other ladies were sitting there with me." Record review and interviews with the facility staff indicated that R5 is interviewable.
2) R7 stated to surveyor. "He (R1) came into my room, I got him out of here, he never touched me, but he had tried to grab me, I was scared to death of him, I stayed away from him." "I don't remember if I ever reported him trying to grab me." Record review and interviews with the facility staff indicated that R7 is interviewable.
3) R8 stated to surveyor. "He (R1) would wander into our room and turn off the air conditioner, the TV and lights." "There was one time, he wandered into my bathroom when I was sitting on the stool."
"I yelled at him and he left." "The second time he came into the bathroom, he took my hand and put it in his, but he never ever tried to touch me in the wrong places." " I told the staff what happened, and they told me to just tell him to go home, so that is what I did after the second time he came into the bathroom with me." "When I told him to go home, he would turn around and leave, but my roommate (R5) was afraid of him, I wasn't afraid of him, he just made me mad that he turned everything off when he came into the room." Sometimes he would come into the room, and stand over R5's bed, and I would tell him to go home, and he would leave, but she (R5) was really afraid of him, he didn't bother me as much as he did her, I grew up with brothers so I wasn't afraid of him." "He didn't know what he was doing."
Record review and interviews with the facility staff indicated that R8 is interviewable.
4) During interview with Z2, Physician, on 8-26-02, Z2 indicated that R1 had been reviewed
and medications had been attempted in dealing with R1's behaviors. Z2 further indicated that R1 had not been sent out for psychological evaluation(s) after 3-22-02 until incidents of 7-29-02 and 7-30-02.