IDPH has cited and fined West Chicago Terrace when a resident sexually assaulted his roommate, resulting in the resident / aggressor being arrested and charged with two counts of domestic battery.
The resident in question had a history of hypersexual and socially inappropriate behavior. The abuse occurred when one resident got on top of another while he was in bed, held down his arms, and sexually assaulted his roommate. The victim reported the incident to staff, stating he was “surprised when his roommate got on top of him while he was in his bed” and that “while his roommate was on top of him, his roommate had his private parts exposed.”
The facility was aware of the resident’s escalating sexual behaviors prior to the incident, as evidenced by multiple documented instances of inappropriate sexual comments and actions towards staff and residents. The resident’s psychiatrist had noted that the resident “is more hypersexual.” However, the facility failed to implement adequate interventions to protect other residents from potential abuse.
Staff interviews revealed that the resident regularly wandered the halls, entered other residents’ rooms, and masturbated in his bed with the door and curtain open. CNAs reported feeling uncomfortable and afraid of the resident’s aggressive behavior when redirected. The Director of Nursing acknowledged being aware of the resident’s escalating sexual behaviors and that “when the PRSC or the PRSD would talk to the resident, the resident was not directable or would say he was “sorry” for his behavior but still would repeat the same sexual behavior.”
Following the incident, police were called, and the resident was arrested and charged with two counts of domestic battery. The facility implemented a removal plan, which included reassessing the resident for abuse risk, updating his care plan, providing emotional counseling, and educating staff on identifying and managing hypersexual behavior in residents. The facility also developed a new policy on managing sexually inappropriate behavior and implemented a QA monitoring program to prevent future incidents of sexual abuse.
Unfortunately, the facility had multiple shortcomings:
1) Failure to protect the resident / victim from sexual abuse by the resident / aggressor, despite being aware of the aggressor’s escalating hypersexual and socially inappropriate behavior.
2) Inadequate interventions to address the resident’s known sexual behavior, which put other residents at risk. Staff primarily relied on redirection and counseling, which were often ineffective.
3) Lack of communication among staff regarding the resident’s behavior, as evidenced by some staff members being unaware of his masturbation habits.
4)Insufficient care planning to manage the resident’s hypersexual behavior. The resident’s care plan was not updated to include additional interventions after multiple instances of inappropriate sexual behavior were documented.
5) Failure to provide a safe environment for residents, as staff reported feeling uncomfortable and afraid of the resident’s aggressive behavior when attempting to redirect him.
6) Inadequate staff training on identifying and managing hypersexual behavior in residents, as well as on abuse prevention policies and procedures.
7) Lack of a specific policy and procedure to guide staff in caring for residents with inappropriate sexual behavior or hypersexual behavior until after the incident occurred.
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