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F0609
D

Failure to Timely Report Alleged Sexual Abuse to State Agency

Chicago, Illinois Survey Completed on 09-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its abuse policy and procedure by not reporting an allegation of sexual abuse to the State Agency within the required two-hour timeframe. A resident with diagnoses including major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder, who was cognitively intact, reported being sexually assaulted while out on pass with a family member. The resident communicated the assault to the Assistant Director of Nursing via text message, who then informed the Administrator. Despite the facility's policy requiring immediate reporting of abuse allegations to the Illinois Department of Public Health (IDPH) within two hours, the Administrator delayed the report until the following day, citing conflicting stories and lack of disclosure to hospital staff upon the resident's return. The initial report to IDPH was made more than 20 hours after the resident returned to the facility and disclosed the assault. Documentation shows that the resident described the assault, underwent a nursing assessment, and a police report was eventually filed. The facility's own policy clearly states that all allegations of abuse must be reported to IDPH immediately, not exceeding two hours after the initial allegation is received, but this protocol was not followed in this case.

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