Failure to Report Resident’s Sexual Abuse Allegations to State and Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report a resident’s allegation of sexual abuse to the Illinois Department of Public Health (IDPH) and local law enforcement as required by policy. The resident had multiple diagnoses including congestive heart failure, type 2 diabetes, Alzheimer’s disease, dementia with behaviors, major depressive disorder, and schizotypal disorder, and had refused a formal cognitive assessment, though a surveyor later determined she was alert and oriented to person, place, and time. Her care plan documented Alzheimer’s dementia with visual hallucinations, long-held delusions, agitation, and a history of combative behaviors that had improved over the past quarter. On one occasion, a CNA reported to a nurse that the resident stated a CNA was not allowed in her room because the CNA had “molested” her. In a later interview, the resident again stated that a staff member had molested her, though she declined to identify the person or involve the Ombudsman. The facility conducted an internal investigation documented as an accusation that a CNA molested the resident, with statements obtained from the involved CNAs and a conclusion that the claims were unfounded and non-credible. There was no documentation that IDPH or local police were notified of the allegation. Social Services described the incident as occurring during toileting, when the CNA allegedly pinned the resident against the wall while cleaning her. The CNA involved reported that the resident had first made an allegation in a prior month, after which she was told not to care for the resident and believed there was no investigation. The Administrator, who serves as the abuse coordinator, acknowledged that this situation had been ongoing since an initial allegation earlier in the year and confirmed that neither the initial nor subsequent allegations were reported externally, explaining that they were unsure if the later statement was a new allegation and that if every allegation from this resident were reported, surveyors would be present frequently. This inaction occurred despite the facility’s written Abuse Prevention Policy stating that all incidents of abuse, including sexually based incidents, are to be reported to the state within 24 hours, with a completed investigation within 5 days, and that if staff are unsure an incident meets the definition of abuse, the policy is to report.
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