IDPH has cited and fined Carmi Manor & Rehabilitation nursing home in Carmi after multiple residents there were assaulted and generally terrorized by a fellow resident over a period of months.
When a resident is being considered for admission to a nursing home, one of the judgments that the admissions staff must make is whether there resident has care needs which would make him unsuitable for the facility or has care needs which cannot be met at the facility. This is an especially critical judgment where a resident has a demonstrated history of psychiatric and behavioral issues which demonstrate a pattern of aggressive or threatening behaviors because a nursing home is often filled with residents who due to physical or mental infirmities may not be able to fend off an aggressor.
The nursing home administration here made a horrifically bad decision to admit this resident and then compounded the problem by failing to train or empower the staff as their proper role in protecting residents and then failing to report and/or investigate abuse that this resident perpetrated on his fellow residents.
The resident at issue was 62 years old (relatively young for a nursing home setting) and had no major physical limitations, but had a current diagnosis of paranoid schizophrenia and had a history of physically and sexually aggressive behaviors. This included a history of having been found unfit to stand trial on rape charges which had previously been lodged against him. Despite this history, the administrator and social services director decided to accept this resident into the facility.
The citation itself is lengthy, and documents at length a disturbing pattern of behavior against his fellow residents. There were seven residents who were victimized by this one resident, both male and female. The male residents were punched and threatened and had their cigarettes stolen from them. Most of the victims were female and they described mainly one of two behaviors. Either they were physically grabbed on the breast by this resident. The other behavior which was directed toward female residents was that he would enter their room proclaim that the female resident was his wife, and act as though he would want to have sex with them. Needless to say this terrified the female residents in the room. The staff would at times simple remove him from the room, but at other times, residents would use their cell phone call 911.
The responses to the calls to 911 were especially disappointing. In one instance, law enforcement simply responded by calling the nurse’s station. One nurse related to the surveyor that the local police department refused to make an arrest because they did not want a psychotic person in their jail. So, of course, they left that psychotic person in a nursing home.
The victims of this resident’s behavior was not limited to his fellow residents. There were staff members who were manhandled and groped. One CNA found herself alone in a room with him with the door closed and screamed because she was afraid of what he would do to her. This was clearly a situation where the staff was not in control of the nursing home.
When a resident is victimized in a resident-on-resident assault, it is incumbent upon the administration to determine whether that resident should remain in their facility. If they cannot keep residents safe, then they need to take steps to discharge the resident. If they believe that the behavior can be managed, then resident abuse prevention care plans need to be modified to take specific and aggressive measures to deter further episodes of abuse. This is another area of failing, as the staff told residents who complained of this resident’s behavior on multiple occasions that they could not do anything about it because they didn’t see this themselves. There really isn’t even a kernel of truth in that. If the staff truly believed that, it represents a massive failure to train. If the staff didn’t actually believe that to be true, it represents a massive failure of leadership because the staff knew that they would not be supported. My guess is that the latter is probably the case because many of the incidents which were described in the citation were never investigated by the administrator who does have an affirmative duty to investigate allegations of abuse.
The net effect of these widespread, repeat failures at this nursing home is that these residents were victimized repeatedly by a resident who likely never should have been admitted in the first place, but was then allowed to stay long after it should have been obvious that this was not a proper resident to have in the facility. A nursing home is a “home” for many residents where they live full time. They do not deserve to be terrorized in their own home. They do deserve to be defended from this kind of nursing home abuse, but there were choices made here to not provide the residents with the level of protection they deserved.
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