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F0609
D

Failure to Immediately Report Resident-to-Resident Sexual Abuse Allegation

Elmwood Park, Illinois Survey Completed on 04-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately report an allegation of resident-to-resident sexual abuse to the Illinois Department of Public Health (IDPH) and local law enforcement. The incident involved a resident who reported to an LPN that his roommate had inappropriately touched him in the lower back and buttocks area during the night. The LPN relayed this information to the Social Service Coordinator, who then informed the Administrator. Despite being made aware of the allegation on the same day it was reported, the Administrator did not notify IDPH or the police at that time, as he concluded after interviews that the allegation was fabricated. Interviews with facility staff, including the Director of Nursing and Social Service Director, confirmed that the proper protocol for such allegations is to report them immediately to the state and law enforcement. The Social Service Coordinator documented the allegation in a progress note and reported it to the Administrator, but no external reporting occurred until several weeks later, when the facility finally contacted the police and submitted an initial report to IDPH. The police confirmed that they were not notified at the time of the alleged incident. The resident involved had a history of cognitive impairment, with a Brief Interview for Mental Status (BIMS) score indicating moderate impairment, and diagnoses including aphasia, dementia, and bipolar disorder. The facility's own abuse prevention policy requires immediate reporting of any abuse allegations to both state authorities and law enforcement, particularly in cases of sexual abuse between residents. Despite these requirements, the facility delayed reporting the incident, failing to follow established protocols.

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