Failure to Report Abuse Allegation Involving Resident's Oxygen and Call Light
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by its own policy and regulatory standards. A male resident with Amyotrophic Lateral Sclerosis (ALS), who was alert and oriented, reported that a Certified Nursing Assistant (CNA) attempted to break his oxygen concentrator by hitting it, then turned it off, and also disabled his call light by pulling it out of the wall. The resident stated he informed a nurse about the incident, and an internal investigation was conducted. Multiple staff members, including the Administrator, DON, and nursing supervisors, were made aware of the allegations. The CNA involved was suspended during the investigation. Despite the seriousness of the allegations, including purposeful interference with life-sustaining equipment and communication devices, the Administrator decided not to report the incident to the Illinois Department of Public Health (IDPH), stating it was not considered a major abuse case. The facility's Abuse Prevention and Reporting Policy requires immediate reporting of any abuse allegations to the Department of Public Health, but this protocol was not followed in this case.