F0610

D

Failure to Investigate and Report Alleged Resident-to-Resident Abuse

Glenwood, Illinois Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The facility failed to follow its abuse policy by not investigating an alleged physical abuse incident involving a cognitively impaired male resident with multiple chronic medical conditions, including chronic respiratory failure, COPD, major depressive disorder, asthma, hypertension, type 2 diabetes, difficulty in walking, and abnormal posture. The resident, who had a BIMS score of 12/15 indicating moderate cognitive impairment, reported that a few weeks prior his former roommate beat him up at night, punching him more than six times in the left lower chest area and causing what he described as a broken rib. He stated he was angry that he was moved to another room instead of the roommate and reported that staff did not assess his left ribs, which he said continued to hurt. Review of the facility’s abuse reportable binder for January through March did not show an incident report for this event.

An LPN confirmed that on a late evening in January she heard a loud verbal altercation between the resident and his roommate, entered the room, and immediately removed the resident. The LPN stated the resident told her the roommate had slapped him, and she reported assessing the resident and notifying the former DON and the resident’s physician. The former roommate denied ever fighting with, punching, or slapping anyone. The current Administrator and DON stated they were unaware of the incident, and the Assistant Administrator confirmed that no investigation had been initiated. The Regional Nurse Consultant and Assistant Administrator acknowledged that an investigation should have been started and reported to the state health department immediately, in accordance with the facility’s abuse policy, which requires that all incidents and any allegation involving abuse be documented, investigated, and reported within specified time frames.