F0609

D

Failure to Report Resident’s Fear and Possible Abuse by Spouse to Administrator

Chicago, Illinois Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Abuse Prevention Program policy requiring that any alleged violations involving mistreatment, abuse, neglect, exploitation, or reasonable suspicion of a crime against a resident be immediately reported to the Administrator. One cognitively intact resident (R1), a 48‑year‑old with major depressive disorder, depression, and schizophrenia, was married to and shared a room with another cognitively intact resident (R2), a 42‑year‑old with schizoaffective bipolar disorder and alcohol abuse. R1 reported a history of several physical altercations with R2 prior to admission, though her trauma screening at admission indicated she denied any prior abuse history. While in the facility, R1 described escalating concerning behavior by R2, including renewed alcohol and marijuana use, increased aggression, and reports of hearing voices, which she did not report to nursing.

R1 stated that on one occasion R2 became angry, grabbed her wallet, dumped all her cards into the toilet, urinated on them, forced her to retrieve the cards from the toilet, tore up her Social Security card, and called her derogatory names. R1 also reported that on another day, which she identified as a Monday, she went to the social worker (V4) and told her that R2 was scaring her and making her feel nervous, and that R2 had dumped her wallet into the toilet. R1 stated that V4 told her that R2 was her spouse and that they needed to work it out as a married couple. R1 did not tell V4 at that time that R2 had physically abused her in the past. R1 later reported that on a subsequent day, in their room with the door closed, R2 punched her in the cheek/face after telling her not to talk about him to anyone. She did not yell for help, did not report this incident to facility staff, and stated that her face did not bruise or swell.

V4 confirmed that R1 came to her office earlier in the week and reported that R2 sometimes drank alcohol. V4 observed that R1 kept looking out the door and stopped talking when someone walked past, and that R1 said she felt afraid and nervous with R2 and that R2 did not want her to say anything. V4 stated that R1 then ended the conversation and left the office, and that later that same day R1 and R2 together requested and were granted a community pass, appearing calm and peaceful before and after the pass. V4 stated she was confused by the information and intended to report it to the Administrator but wanted to gather her facts first. She did not immediately report R1’s expressed fear and nervousness about R2 to the Administrator, despite having received abuse training and knowing the Administrator was the abuse coordinator. The Administrator later stated she had not been made aware that R1 felt afraid or nervous being in the room with R2 or that R1 was being abused by R2, and that her expectation was that any staff member who learned a resident was afraid or nervous around another resident or staff member would notify her immediately. The facility’s written Abuse Prevention Program policy requires that any alleged or suspected incident of resident abuse be promptly reported to the Administrator, which did not occur in this case.