Failure to Timely Report and Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to timely report and investigate allegations of abuse between two residents, as required by state regulations and facility policy. Multiple staff interviews and record reviews revealed that one resident repeatedly reported being verbally harassed, threatened with violence, and subjected to derogatory and discriminatory language by another resident. The affected resident expressed feeling unsafe, emotionally distressed, and unable to sleep due to ongoing threats and harassment. Despite these reports, there was no evidence that the initial and final reports of the abuse allegations were sent to the Illinois Department of Public Health (IDPH) as required. Staff interviews indicated that the abuse allegations were communicated to various facility personnel, including the receptionist, social services, nursing staff, and management. Documentation in the resident's clinical records confirmed that the resident reported threats of violence and derogatory language, and that staff were aware of the situation. However, staff responses varied, with some staff stating that the incident was not considered abuse and therefore not reportable, while others acknowledged the seriousness of the threats and the need for investigation. There was a lack of consensus and clear documentation regarding the investigation process, and the facility was unable to provide evidence of a thorough investigation or timely reporting to IDPH. Both residents involved were cognitively intact and able to communicate their experiences. The resident accused of making threats had a documented history of verbal aggression toward staff and other residents. Despite ongoing complaints and documentation of threatening behavior, the facility did not separate the residents or take sufficient action to ensure safety, nor did it fulfill its obligation to report the allegations and investigation results to the appropriate authorities within the required timeframes.