Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse or neglect involving a resident who reported that a nurse yelled at him after he waited for an extended period for assistance. The resident, who had multiple medical conditions including type 2 diabetes mellitus, chronic wounds, osteomyelitis, and a lumbar vertebra fracture, stated that he waited nearly an hour for help, used his call light, and eventually began yelling to get staff attention. When a nurse 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. Despite the resident's report, there was no documentation of the incident in his medical record, and the facility did not initiate an abuse or neglect investigation at the time. Interviews with the DON and AIT revealed that while the DON was aware of the complaint and spoke with the nurse involved, she did not follow up with the resident after the initial interview and did not document an investigation. The AIT, responsible for investigating abuse allegations, was unaware of the full extent of the complaint and did not report or document the incident as required. The incident was not reported to the State Survey Agency, and no formal investigation was conducted until prompted by the surveyor's inquiry. A grievance form regarding the incident was only completed after the surveyor asked about the event, and the facility's policy defined verbal abuse as including yelling with the intent to intimidate. However, the initial response from facility leadership was to minimize the incident, with the RDO suggesting it may have been a misunderstanding and not meeting the threshold for verbal abuse. The lack of timely and thorough investigation, documentation, and reporting constituted a failure to respond appropriately to an alleged violation.