Failure to Timely Report Allegations of Verbal and Mental Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal and/or mental abuse were reported to the administrator and State agency (SA) in a timely manner for three residents who reported or were observed to have experienced potential abuse. One resident, who had intact cognition but demonstrated delusional thinking, reported feeling abused by her roommate, who allegedly called her derogatory names and swore at her. The resident stated she had not reported the abuse previously, and a nursing assistant confirmed overhearing the roommate calling the resident names about a month prior but did not report it, assuming nurses present had witnessed it as well. There was no evidence that this allegation was reported to the SA until the surveyor brought it to the attention of the administrator and DON, who were previously unaware of the situation. Two additional residents, both with intact cognition and various medical and psychiatric diagnoses, were involved in separate incidents where a facility physician reported allegations of staff verbal abuse to the DON. The physician's progress notes indicated that one resident was called a derogatory name by an unknown staff member and was left uncomfortable and agitated, while the other resident experienced rudeness from staff. Although the DON was informed of these allegations, he did not report them to the SA, and the administrator was not made aware until later, during the survey process. The facility's Vulnerable Adult Abuse Prevention Policy defined verbal and mental abuse and required mandated reporters to immediately report any knowledge or belief of abuse to the administrator, DON, or their designee. Despite this policy, staff failed to report witnessed or alleged abuse in a timely manner, resulting in delayed notification to both facility leadership and the State agency, as required by regulation and facility policy.