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F0609
D

Failure to Report Staff-to-Resident Verbal Abuse Allegation

Cleveland, Ohio Survey Completed on 04-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of staff-to-resident verbal abuse to the proper authorities as required by policy and regulation. The incident involved a resident with a history of dementia, agitation, and behavioral issues, who was alleged to have been verbally threatened by a CNA. Multiple witness statements and interviews indicated that the CNA told the resident she would physically harm him, and this was corroborated by both written and verbal accounts from other staff members. Despite these accounts, there was no documentation of the incident in the resident's medical record, nor was there a Self-Reported Incident (SRI) submitted to the state authorities. The personnel file for the CNA involved showed she was terminated for her actions, and witness statements described her using threatening and profane language toward the resident. Interviews with staff confirmed the occurrence of the incident, with one CNA reporting hearing the threats and another RN stating she heard the resident yelling about being threatened. The CNA herself admitted to making the threatening statement, citing provocation by the resident. However, the Director of Nursing (DON) insisted there were conflicting stories and did not report the incident to the nurse aide registry or submit an SRI. The facility's own policy required immediate reporting of all abuse allegations to the Administrator and to the Ohio Department of Health, with a formal investigation and submission of results within five working days. None of these steps were taken in response to the incident. The lack of reporting and documentation represented a failure to follow both internal policy and regulatory requirements for abuse reporting.

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