IDPH has cited and fined The Terrace in Waukegan after a resident there was sexually assaulted by a fellow resident.
Nursing homes in Illinois serve residents with a variety of issues. Some are in for short term rehab after a surgery; some have chronic long term medical issues which leave them too frail to live at home safely.
Still others have few physical limitations but instead have mental/psychiatric conditions which require long-term care. Sometimes their issues manifest themselves in ways which are physically aggressive toward other residents. When that happens the nursing home has an obligation to keep all of its residents safe.
One of the residents that The Terrace admitted had a host of psychiatric diagnoses including a traumatic brain injury (TBI) and schizoaffective disorder. What he did not have was any significant physical/musculoskeletal disorder, which meant that he was physically capable of acting out on his impulses.
Further, upon admission to the facility, the resident’s admission records consisted only of his demographic sheet and background checks from the previous (sister) facility. No care plan, progress notes, resident assessments, or any documented information identifying the resident’s behavioral history was sent with him upon his admission to the facility.
About two weeks after the resident was admitted to The Terrace, his behavior began to decline rapidly and he became more sexually aggressive. The first behavior note in the resident’s records showed that a staff member had to “provide patient education on keeping hands to self and not trying to poke staff and make them uncomfortable . . . .”
A second note, dated the following day, showed “CNA (Certified Nursing Assistant) reported that the resident would tell her sexual stuff in Spanish that translates into “I want to get between your legs.” It was also reported that the resident had tried to touch the CNA in an inappropriate way. The staff continued to attempt to educate the resident to stop the aggressive behavior, but the “resident just laughs.”
Finally, six days later, a CNA reported the following:
“I saw the resident propelling himself down the hallway, towards the dining room, but he never made it to the dining room. I walked down the hall to look for him. I saw him in another resident’s room so I walked into her room. The resident was lying in bed. The male resident was in a wheelchair, next to the female resident’s bed. The male resident had one hand on the female resident’s breast and his other hand was going down between her legs. I immediately wheeled the male resident out of the room and told the nurse. The female resident can’t consent to anything. She just babbles.”
This is the kind of event that anyone who admits a parent to a nursing home fears most – that their parent will end up being victimized in some way. In this instance, the person who committed this horrific act of nursing home abuse was not a staff member, but a fellow resident. However, this does not relieve the nursing home of responsibility for what occurred because the nursing home failed in at least three aspects: not sharing admissions info, not notifying the physician after the first two incidents, and not supervising the resident adequately.
- The absence of any documented information identifying the resident’s behavioral history upon admission is indicative of a significant breakdown in the facility’s admission procedures. A nurse later explained to the investigator that the resident was transferred out of the original (sister) facility due to the building no longer being habitable. The air conditioning had stopped working and all of the residents had to be transferred to other facilities. While emergency situations such as this do occur, it is no excuse for not transferring with the patient a history of their behavior and their illnesses. That was not a gamble that families of other residents signed up to take. They look to the staff to keep their parents safe.
- They failed to notify the physician of the resident’s sexual behaviors towards the facility staff. The escalating verbal expressions of sexual aggression were significant enough, but when the resident acted on those expressed desires, by trying to touch the CNA in an inappropriate way, this was something that required physician notification, similar to the occurrence of a nursing home fall or the development of a bed sore. The nurse for both residents stated that “had I been notified of his behaviors towards staff, I would have sent him out of the facility, for a psych evaluation, immediately. I would have been concerned about him being a threat to other residents …” If that had happened, the sexual assault likely would never have happened.
- They failed to supervise the resident while he was out of his room. Rather than put the resident on close monitoring or 1:1 supervision after the initial behavior issues with staff, the Director of Nursing instructed the staff members to “redirect the resident and set boundaries.” This proved to be woefully inadequate and ultimately lead to the sexual assault of another resident.
Besides this being an unspeakable violation of this female resident’s body and dignity, it is also important to keep in mind that this is something that took place in her room. Many residents in nursing homes feel like they are at the mercy of the staff and feel vulnerable to begin with. This kind of incident occurring in someone’s room – their home at the nursing home – only serves to exacerbate the underlying feelings of vulnerability that many nursing home residents feel to begin with.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
