Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to immediately report an allegation of abuse or neglect to the State Survey Agency after a resident reported that a nurse yelled at him during a delayed response to his call light. The resident, who had multiple medical conditions including type 2 diabetes mellitus, chronic wounds, osteomyelitis, and a lumbar vertebra fracture, stated that he waited for nearly an hour for assistance, became anxious, and began yelling for help. When a nurse finally entered, she reportedly yelled at the resident in a gruff tone, which the resident found distressing. The resident communicated his concerns to management, expressing that he felt uncared for and upset by the staff's response. Upon review, there was no documentation of the incident in the resident's medical record. Interviews with facility leadership revealed that the DON was aware of the complaint and conducted an informal investigation, speaking with both the nurse and the resident. The DON determined, based on the nurse's account, that the incident did not constitute abuse and did not follow up further with the resident. The AIT, who was responsible for reporting abuse allegations, was not fully aware of the details and did not report the incident to the State Survey Agency or document an investigation at the time. A grievance form was only initiated after the surveyor inquired about the incident, and the facility's policy defined verbal abuse as including yelling with intent to intimidate. The facility's leadership acknowledged that the event should have been investigated and potentially reported, but no immediate report or formal investigation was made until prompted by the survey process. This failure to report the allegation of abuse or neglect in a timely manner constituted the deficiency.