Failure to Report Allegations of Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to report allegations of staff-to-resident abuse to the state agency and the facility administrator as required by policy. One resident with severe cognitive impairment and multiple medical conditions, including major depressive disorder and a need for assistance with personal care, made allegations that a staff member threatened her and that another staff member allowed shampoo to run into her eyes during a shower, causing her distress. The resident's care plan included interventions for behavior management and abuse risk, with instructions to investigate allegations per facility protocol and notify the abuse care coordinator immediately. Despite these protocols, the incident where the resident accused a staff member of threatening her was not reported to the Illinois Department of Public Health (IDPH), and the administrator did not obtain a statement from the resident at the time of the allegation. Staff interviews revealed that the resident had reported being mistreated during a shower, with one CNA witnessing the resident in distress and reporting it to a nurse. However, the nurse did not escalate the report to the administrator, and the administrator was not made aware of the incident until it was brought to her attention by IDPH. The facility's policy required immediate reporting of any incident, allegation, or suspicion of abuse, neglect, or exploitation to the administrator and, in cases of abuse, to the Department of Public Health within specified timeframes. In these cases, the required notifications and investigations were not completed as outlined in the policy, resulting in a failure to follow internal and regulatory reporting requirements for suspected abuse.