Failure to Timely Investigate and Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to investigate and report allegations of resident-to-resident physical abuse to the Illinois Department of Public Health (IDPH) within the required regulatory timeframe. One resident stated that a roommate entered the shared room, knocked belongings to the floor, swung the resident around from behind, and struck the resident on the right side of the jaw. The resident reported this incident to the nurse, and the alleged aggressor was sent to the hospital that day; however, review of the electronic health record progress notes showed no documentation that the aggressor hit the resident. Another resident reported that the same alleged aggressor entered the room, requested money, and when refused, became angry, cursed, and threw a water pitcher that struck the resident’s face, spilling water and ice. This second incident was documented in a progress note, which stated that the resident clearly verbalized that another resident threw a pitcher of ice water into the resident’s face. Nursing staff interviews revealed that one RN understood the contact as a form of abuse and stated that the incident was verbally reported to the administrator, and an LPN stated that the water-pitcher incident was reported to the administrator, who serves as the abuse coordinator. In contrast, the administrator reported not being informed of any abuse by the alleged aggressor, stating that the administrator only became aware of the water-throwing incident upon reviewing the progress note during the week of the survey and that the LPN said she did not know she was supposed to report it. The administrator also stated not being made aware of the alleged hitting incident and that the RN did not report it. This occurred despite existing facility documents, including an in-service on abuse education, a statement of resident rights requiring immediate reporting of alleged violations to the administrator and as required by state law, an abuse prevention policy, and a job description for the administrator that includes responsibility for compliance with federal, state, and local regulations.
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