IDPH has cited and fined Dixon Rehabilitation & Healthcare Center 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 Dixon Rehab admitted had a host of psychiatric diagnoses: frontal lobe dementia, delusional disorders, generalized anxiety disorder, pseudobulbar affect, restlessness and agitation, and a series of other diagnoses. What he did not have was any significant physical/musculoskeletal disorder, which meant that he was physically capable of acting out on his impulses.
The resident was admitted in June, but was sent out of the facility for a psychiatric admission after a resident-to-resident altercation. When he was readmitted to the facility in mid-September, a care plan was put into place to monitor for and record inappropriate behaviors, including those directed at other residents. His location was supposed to be checked every 15 minutes and supervised when he was wandering the halls to prevent entry into the rooms of other residents.
About a month after this resident was readmitted to the facility, his behavior began to decline rapidly and become more sexually aggressive. The citation describes multiple episodes where he maded sexually inappropriate comments to female staff members and guests of the nursing home. He began to express a desire to kiss other residents, to have sex with them, and a nurse was told that he said with regard to another resident, “I want her, can I have her?”
Besides the verbal expression of sexual aggressiveness, there was an incident October 27 where he sat next to a female resident on a resident on a couch and touched her side, waist, and legs. The staff was made aware of this incident and the began to seat the resident in between other male residents in the dining room so as to prevent further incidents of touching or kissing but the care plan was not formally updated to include this. More importantly the psychiatric nurse practitioner was not notified of the incident by the nursing staff, as she told the state surveyor she would have sent the resident to the hospital had she been notified of the incident. She had been notified of escalating sexual behaviors and was attempting to bring these under control through medication. The staff had begun to have conversations with the resident’s wife about having him placed in a different facility where men and women were housed separately.
In general, the resident spent most of his time in his room, and checks were supposed to be done every 15 minutes, but his wife reported that there were time where she would be in his room for hours without interruption by the staff. On November 22, he left his room and was seen walking in the hallway by two CNA’s who were moving a chair to the dining room. After returning to the hall to get a pad for the chair from the linen cart, she recognized that resident was not in the hallway. She then heard a female resident in her room saying, “That hurts.” The aide entered the room and saw him standing over the female resident pulling a blanket back over her waist. Asked what he was doing, the resident replied, “I was fingerf***ing her.”
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:
- It continued to keep this resident in the facility when the staff clearly recognized that he required care beyond their ability to deliver. The sexual behaviors had been escalating rapidly, and the staff recognized that they were in over their heads when they began to discuss alternative placements with the resident’s wife. One of the basic truisms in the nursing home industry is that you should not accept as a resident and should not keep as a resident anyone whose care needs cannot be met. They recognized that the resident’s behaviors were escalating beyond their ability to address it, but chose to keep him in the facility. When the discussions were being had with the resident’s wife, actin had to be taken also because each day they kept him in the facility after that was a day where they ran a risk that this kind of incident would take place. That was not a gamble that families of other residents signed up to take. They looked to the staff to keep their mother safe.
- They failed to notify the nurse practitioner of the October incident. The escalating verbal expressions of sexual aggression were significant enough, but when the resident acted on those expressed desires, 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 practitioner inidcated to the state surveyor that this would have resulted in an in-patient psychiatric admission, and if that had happened, this likely never would have happened.
- They failed to supervise the resident while he was out of his room. This is what the care plan called for, but instead of executing the plan, the aides moved the chair into the dining room. Obviously, this was not a task that took a long time, but that was all that it took for this resident to act out on a woman who was sinmply laying in bed in her room. There should be zero argument that keeping residents safe is infinitely more important that moving furniture.
Besides this being an unspeakable vioaltion 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 undelrying 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 residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. 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.
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