Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of sexual and verbal abuse involving two residents, as required by its abuse prevention policy. In the first incident, a female resident with severe cognitive impairment and under hospice care was found in her room with a male resident who had exposed himself and remained alone with her for approximately eight minutes. The incident was observed by staff and confirmed by video surveillance. Despite the clear identification of sexual abuse, notifications to the resident's Power of Attorney (POA), physician, the Illinois Department of Public Health (IDPH), and local police were significantly delayed, with the POA and IDPH notified six to seven days after the incident and the police notified ten days later. Both the hospice and primary physicians confirmed they were not informed, which prevented timely evaluation or treatment. In the second incident, a resident with moderate cognitive impairment sustained a skin tear and bleeding after being startled by another resident's shouting during a verbal altercation. This abuse allegation was also not reported to IDPH until six days after the event. The facility administrator attributed the delays in both cases to being new in the role. The facility's abuse prevention policy explicitly requires immediate notification of the resident's representative, physician, and local police in cases of suspected criminal activity, which was not followed in these instances.