Maple Ridge Care Centre

Facility I.D. Number: 0042366

2202 N. Kickapoo St.

Lincoln, IL 62656

Date of Survey: 3/5/04

Complaint Investigation


An owner, licensee, administrator, employee or agent of a facility shall not abuse a resident. A facility employee or agent who becomes aware of abuse of a resident shall immediately report the matter to the facility administrator.

Based on interview, observation and record review the direct care staff failed to immediately and factually report an incident of abuse to management. R1 was abused by E5. R1 sustained a black eye. The facility failed to protect R1 and the other thirteen residents assigned to his care. E5 was allowed to complete the shift and return the following day to complete approximately two thirds of another shift. Seven staff members, (E3,4,5,6,8,9&13) were aware of E5 hitting R1 but did not report this to E1.

Findings include:

1. The admission face sheet of 09/04/02 confirms that R1 is a 67-year-old male who was admitted to the facility on 09/04/02. Review of the February 2004 physician order sheet confirms that R1 has diagnoses of Alzheimer's, Dementia (other than Alzheimer's), Diabetes, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. The nursing assessment dated 02/13/04 indicates that R1 has moderately impaired cognitive skills, both long and short term memory problems, and requires staff assistance for transfer, bathing, dressing and toilet use. It indicates that R1 requires a wheel chair for mobility.

On 02/20/04 at 01:20 p.m., R1 was observed to have swelling and bruising to the left eye area from just below the eyebrow down through the bag under R1's eye. The white of the eye (sclera) was noted to be red and bloodshot. This was confirmed by E6 (Licensed Practical Nurse/LPN) during interview. No evidence of bruising to the cheek could be found.

Review of the facility incident report dated February 18, 2004 at approximately 08:00 a.m. indicates "An alert resident in a wheelchair and that has some confusion, (R1), was being combative with care. He was scratching and hitting (E4 Certified Nursing Assistant/CNA). While striking out at (E4), (R1) then stood up and lunged at (E4). When (R1) lunged, (R1) fell into wall striking left side of face. (E4) did catch resident from falling to the floor." Interviews were conducted on 02/20/04 in the afternoon with E3 (CNA),E6 (LPN),E7 (LPN) & E8(Housekeeper). E9 (Rehabilitation Aide) was interviewed on 02/24/04 at 09:40 a.m.. Information obtained from these interviews was the same information stated in the incident report.

E1, (Administrator), stated in interview on 02/20/04 at 09:00 a.m. that she was unaware of any allegations of abuse until yesterday, 02/19/04 when Z3, (Police Investigator) entered the facility sometime in the mid-morning. "(Z3) started asking questions and I asked him point blank, was this involving abuse, this was the first I knew of any allegation of abuse." "(Z3) looked at the records, spoke with (E4,5 &6) and felt that abuse did not occur."

At approximately 10:00 a.m. on 02/20/04, E1 reported, "We received a phone call from (E3, CNA) and she wanted to change her story, as she had witnessed (E5) with his arm drawn back and a fist made in the direction of (R1)." During interview with Z3 at 10:03 a.m., he stated that due to E3 coming forward Z3 would be re-interviewing the staff.

Interviews with staff members, review of staff statements given to Z3, and the facility investigation indicate staff knowledge that R1 was abused on 02/18/04. This abuse was not reported until 02/20/04. Interviews were:

  1. During interview with E2 (Director of Nursing), on 02/24/04 at 11:30 a.m., E2 was asked why E3 did not report to her that E5 had hit R1 on 02/18/04. E2 stated that she had asked E3 why she did not report and E3 had said, 'I'm a nobody and nobody would believe me.' E2 said that E3 knew that E4, E5, and E6 were all good friends.

  2. During interview with E13 (CNA) on 02/25/04 at 10:13 a.m.. E13 reported, "That day (02/18/04) (E3) & I heard a noise in (R1's) bathroom, (E3) opened the door, yelled (E5's) name, grabbed her head and then nearly ran over me as she left. I was standing right behind her as she opened that door. I couldn't see in there but I felt I knew (E5) had hit (R1)." During telephone interview with E13 on 2/26/04 at 09:36 a.m., E13 reported, "I didn't report it because I saw (E3,4,&6) discussing it so I thought they would take care of it". When E13 was asked why E3 did not report it, E13 stated, "Because (E3) said,' no one would believe her.'"

  3. 3. E3 reported in an interview at 01:05 p.m. on 02/20/04 that, "I said something to (E9) (Rehabilitation Aide) about it (E3 witnessing E5 with his arm drawn back and a fist made) and (E9) said, 'I already know about it, (E8) (housekeeper) told me.'"

    During interview with Z3 on 02/24/04 at approximately 03:00 p.m., Z3 said that he had written confessions from (E4,5&6). E5 had confessed to hitting R1. E5 and E6 had confessed to covering up the incident.

These statements were reviewed on the following day. Review of E4's statement reports, "When I went in to get (R1) up for breakfast (R1) was soaked. We had no problems getting to the bathroom. When I asked him to take off his pants from around his ankles, he became agitated, began punching me. He started punching me again when I reminded him to take off his pants. That's when I stopped trying to get him cleaned up, went down the hall to get (E5). I showed him my arms, shoulders, chest - they were red from (R1) hitting me. I then went back to (R1's) bathroom. In walked (E5). I wasn't sure, when (E5) walked in what was going to happen. Whether (E5) was going to do something to (R1) or what. And I shouldn't have went down to get (E5) but I did because (R1) is always like that. I left the bathroom to get wash rags. I came back to the room. (E5) was walking out already and he kinda smiled. I went on in to the bathroom. That's when I noticed (R1's) eye was red & his nose was bleeding a little. I didn't see (E5) hit (R1) but I know he did because he told me. It was my idea to cover (E5) so he wouldn't get into trouble. Later on that day (E5) told me he had hit (R1) in the eye."

Review of E5's 02/24/04 statement to Z3 reports, "I had gone to (R1's) room to help (E4). (E4) left to get wash clothes, I bent down to take (R1's) sock off. As I bent over (R1) punched me in the back of the head. I swung up with my right hand, caught him in the face. Later on in the day, I told another employee that (R1) will have a shiner tomorrow."

E6's 02/24/04 statement to Z3 reports, "(E4) approached me telling of (R1) lunging at (E4). I began filling out the incident report when (E9) (Rehabilitation Aide) approached me at the desk and said, 'It’s a rumor going around that (R1) may not of hit the wall, he may have been hit.' Later, (E3) asked me if I thought (R1) really hit the wall. I said yeah, sure. I lied about the incident because (E4) is my friend."