Failure to Report Abuse Allegation as Required
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who was cognitively intact and dependent on staff for bathing and showers. The resident, who had multiple diagnoses including hemiplegia, major depressive disorder, seizures, osteoarthritis, contractures, and schizophrenia, reported experiencing pain during care, specifically when being changed and showered by a particular CNA. The resident expressed to staff that she did not want this CNA to care for her anymore due to the pain caused during these interactions. Multiple staff members, including CNAs and a nurse, observed or were informed of the resident's distress and complaints of rough care, including being pulled and having cold water put on her during a shower. On the day of the incident, the nurse on duty heard the resident crying and, upon inquiry, was told by the resident that the CNA had been rough during the shower. The nurse reported the incident to the supervisor, who then sent the CNA home pending investigation. Several staff members wrote statements about the incident and placed them in the administrator's mailbox, as per facility protocol. The Director of Nursing was notified and instructed that an assessment be completed to check for bodily injury, and a grievance form was filled out. The administrator was also notified but did not respond to the allegation until after the weekend. Despite the facility's policy requiring immediate reporting of abuse allegations to the Department of Public Health and documentation of all incidents, the administrator did not report the incident to the Illinois Department of Public Health. There was also uncertainty among staff regarding the status and handling of the investigation, with some staff not being interviewed and the Director of Nursing stating she had not received any written statements. The failure to report the abuse allegation as required by policy and regulation constitutes the deficiency.