Failure to Timely Report and Investigate Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Prevention Program Policy by not reporting an allegation of physical abuse between two residents to the Illinois Department of Public Health (IDPH) within the required two-hour timeframe. The incident involved a cognitively impaired male resident with multiple medical conditions, including Parkinson's Disease and schizophrenia, who was physically assaulted by another male resident with a history of violent behavior and psychotic disturbance. The assault resulted in visible injuries, including a bruised and discolored eye, and required emergency medical attention. Staff present at the time of the incident separated the residents and notified facility leadership, but the initial report to IDPH was not submitted until ten days after the event. Additionally, the facility did not submit the final investigation report to IDPH within the mandated five business days. The administrator acknowledged the delay and indicated that the final report was not uploaded until more than a month after the incident. The facility's policy requires immediate reporting of abuse allegations and submission of the final investigation report within five working days, but these procedures were not followed in this case, as confirmed by interviews and record reviews.