Failure to Timely Report Alleged Abuse and Misappropriation of Property
Penalty
Summary
The facility failed to immediately report an allegation of staff-to-resident abuse to the administrator and did not identify or report an incident of possible misappropriation of a resident's property to the Illinois Department of Public Health for two residents. In the first case, a resident with moderately impaired cognition and multiple diagnoses, including dementia and chronic pain, reported that a Certified Nurse Assistant (CNA), who was also the administrator's son, took her into her room, shut the door, grabbed her around the arms and chest, squeezed her until it hurt, and then took her wheelchair away. Multiple staff members were aware of the incident, with some hearing the resident yelling for help and others being told directly about the incident. However, several staff did not report the incident immediately, either because they were unaware of the reporting requirements or assumed someone else had already reported it. The administrator was not informed until the following morning, and there was a delay in initiating an investigation and notifying authorities. In interviews, the CNA involved denied harming the resident but admitted to taking her to her room, raising his voice, and removing her wheelchair. Other staff corroborated that the resident was upset and that her wheelchair was taken away, with one LPN stating that removing the wheelchair constituted a restraint. The administrator, upon being notified, did not arrive at the facility until later in the day and did not immediately report the incident to the Department of Public Health. The facility's policy requires immediate internal and external reporting of any allegations or suspicions of abuse, neglect, or misappropriation, but this protocol was not followed in this case. In the second case, another resident reported that $200 was stolen from his room while he was hospitalized. The resident stated he reported the missing money to the administrator. Staff were aware of the missing money, but the administrator claimed not to know the amount and did not conduct a formal investigation or report the incident to the Department of Public Health. The only documentation was a grievance form, and there was no paper trail of any investigation or communication with authorities. The facility's policy mandates immediate reporting and thorough investigation of such allegations, but this was not adhered to in this instance.