Failure to Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an abuse allegation to the Illinois Department of Public Health (IDPH) for one resident who was admitted with multiple diagnoses, including severe cognitive impairment and communication deficits. Upon a family visit, discoloration was observed under the resident's left eye, which was not present at admission. The administrator and DON assessed the resident in the presence of family, and the resident reported that something had fallen on her head during ambulance transport to the facility. The administrator contacted the ambulance company to investigate, and the resident's physician was notified, resulting in an x-ray that was negative for injury. The ambulance company later reported no incident during transport. Despite the resident's report of an object falling on her head and visible injury, the administrator did not submit an abuse allegation report to the state agency, as the resident stated the incident was unintentional and the ambulance company denied any incident. The facility's reportable binder did not contain documentation of the incident, and the administrator determined that, since the resident could explain the injury and denied intent, it did not meet the threshold for reporting to IDPH. This decision was made despite facility policy requiring investigation and reporting of unexplained injuries and abuse allegations.