Failure to Timely Report Alleged Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report allegations of abuse involving four residents, as required by regulation and facility policy. In one incident, two residents with moderate cognitive impairment were observed physically striking each other, with one resident repeatedly hitting the other and both engaging in aggressive behavior. Despite the altercation being witnessed by a safety aide and other staff, there was no documentation of the event in the medical records, no report made to the Illinois Department of Public Health (IDPH), and the residents remained roommates. The administrator and registered nurse were not made aware of the incident until it was brought to their attention by a state surveyor, and the safety aide did not report the incident as abuse. Another resident with a history of physical aggression exhibited agitated and aggressive behaviors, including yelling, cursing, and pushing another resident's wheelchair. These behaviors were documented in progress notes, but the incidents were not reported or investigated until days later, when the DON became aware and reported them to IDPH. The nurse documented the events as late entries, and the DON stated that she would have expected immediate reporting of abuse. A separate incident involved a resident with Huntington's Disease and a history of abuse, whose roommate, a resident with severe cognitive impairment, was found standing by her bed holding a pillow. Although no physical contact occurred and the residents denied any harm, the CNA who observed the event was concerned. The facility's investigation concluded that there was no reportable issue, and no separation of the residents or report to IDPH occurred. The facility's abuse prevention policy requires immediate reporting of alleged violations, but this was not followed in these cases.