Failure to Investigate Alleged Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to investigate allegations of resident-to-resident physical abuse involving two residents after an incident in which one resident was allegedly pushed by another, causing a fall and injury. The facility’s abuse prohibition policy, revised 1/29/2026, requires the Administrator or designee to investigate all alleged incidents of abuse after an initial report of suspected abuse or neglect is sent to IDPH. A health status note dated 12/2/25 documents that one resident had a physical altercation with another resident that resulted in a fall and required transfer to the emergency room. A progress note dated 12/28/25 shows that the resident returned with a soft cast to the right hand due to a fracture following the incident, and an event note from the same date documents that the resident was pushed by another resident. A health status note dated 12/28/25 further documents that an LPN notified the Administrator about the incident between the two residents, and the LPN stated she called the Administrator on the day it occurred. On 2/20/26 at 3:00 p.m., the Administrator stated he did not investigate the incident, despite acknowledging that he should investigate all alleged abuse reported to him. These findings show that, although the incident, injury, and alleged abuse were documented and reported to the Administrator as required by facility policy, no investigation was conducted into the alleged resident-to-resident physical abuse involving the two residents.
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