Failure to Investigate and Respond to Allegations of Verbal and Mental Abuse
Penalty
Summary
The facility failed to respond appropriately to allegations of verbal and/or mental abuse for three of four residents reviewed. 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 did not always feel safe in her room and had not reported the incidents previously. A nursing assistant confirmed overhearing the roommate calling the resident names in the dining room about a month prior, but did not report the incident, assuming nurses present had witnessed it as well. There was no evidence in the care plan or medical records that the facility had investigated these allegations or implemented interventions to ensure the resident's safety, despite the behavior being witnessed by direct care staff. Additionally, two other residents reported allegations of staff verbal abuse, which were submitted to the State Agency by the facility physician. Both residents had intact cognition and various medical and psychiatric diagnoses. Progress notes indicated that the director of nursing (DON) was informed of the allegations, but there was no documentation of an investigation or any follow-up in the electronic medical record. Interviews with the residents revealed that they felt staff were rude or had made derogatory statements, but they were unable to identify the specific staff member or the timing of the incidents. The DON acknowledged being informed of the allegations but admitted to failing to initiate or document an investigation. Interviews with facility staff, including medication aides and LPNs, confirmed the expectation that all allegations or observations of abuse should be reported immediately to management for investigation. However, the administrator and DON both stated they were unaware of the allegations until informed by others, and no investigation or documentation was completed as required by facility policy. The facility's abuse prevention policy outlined the need for immediate assessment and investigation upon receiving a report, but this was not followed in these cases.