F0609

D

Failure to Report Resident-to-Resident Physical Abuse Allegation to State Agency

Chicago Heights, Illinois Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of resident‑to‑resident physical abuse to the state survey agency. One resident with schizophrenia and bipolar-type schizoaffective disorder (R1), who had a documented history of aggravated battery with great bodily harm and attempted murder and was care planned as an identified offender with potential for physical/verbally aggressive behavior, became agitated toward another resident (R2) in the dining room. R2 had diagnoses of major depressive disorder, PTSD, and nonsuicidal self-harm, was assessed as at moderate risk for abuse/neglect, and had no cognitive impairment. R2 later reported that a heavy-set Black male resident hit him in the head and face more than once in the dining room after an exchange of words, describing the contact as unwanted touching and stating there was definite physical contact and multiple hits before staff intervened.

R1 admitted to the surveyor that he hit R2 in the head with a closed fist because he believed R2 was making fun of his laugh, acknowledging he knew he should not be hitting anyone but was very mad at the time. A behavior aide (V16) reported hearing commotion, going to the area, and seeing R1 give R2 “a couple taps” with a closed fist, and stated this would be considered physical abuse and that all altercations must be reported to a supervisor or administrator. V16 stated that he informed the administrator (V18) about the incident and described the altercation as he later did to the surveyor. Nursing and social service notes for R1 on the date of the incident documented increased agitation toward a peer, responding to internal stimuli, inability to be redirected, 1:1 monitoring, and transfer to the hospital for psychiatric evaluation, but did not document the physical assault itself.

Despite these accounts, the administrator (V18) stated that his internal investigation concluded the incident was “horse playing,” that R1 only admitted to tapping R2 on the shoulder, and that under facility policy there was no need to report the incident. V18 provided an alleged written statement from R2 about the incident, which contained a signature without a date; R2 denied ever seeing or signing the document, and when R2 signed the paper in the surveyor’s presence, the two signatures did not match. Staff who were aware of the event, including the PRSC (V7) and an LPN (V10), either believed or were told it was an attempted hit or verbal altercation and did not confirm with R2 whether physical contact occurred; neither spoke directly with R2 about the incident. There was no documentation of the altercation in R2’s notes, only wellness checks indicating R2 felt safe, and review of abuse reportables for the prior three months showed no incident report submitted to the state agency, despite facility policy requiring employees to report any incident, allegation, or suspicion of potential abuse to the administrator and defining physical abuse as hitting and similar acts.

The facility’s abuse prevention and reporting policy affirmed residents’ rights to be free from abuse and required immediate internal reporting of any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation. The policy defined abuse as willful infliction of injury or intimidation with resulting physical harm, pain, or mental anguish, and physical abuse as non-accidental infliction of injury requiring medical attention, including hitting and slapping. Multiple staff, including V10 and V16, acknowledged that if a resident hits or touches another resident in this manner it is considered abuse and must be reported. Nonetheless, the facility did not treat the event as a reportable allegation of abuse and did not submit an incident report to the state survey agency, resulting in the cited failure to timely report suspected abuse and the results of the investigation to the proper authorities.