Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the Department of Public Health and the Ombudsman within the required two-hour timeframe, as outlined in the facility's Abuse Investigation and Reporting policy. The incident involved a resident with a history of metabolic encephalopathy, COPD, and heart failure, who was assessed as having moderate cognitive impairment and required assistance with activities of daily living. The alleged verbal abuse occurred during an overnight shift when a CNA was reported to have called the resident 'crazy' after the resident became upset about being woken for incontinence care. Documentation showed that the incident was noted in the resident's progress notes and care plan, and staff statements confirmed that the allegation was communicated to supervisory staff. However, the report to the Department of Public Health was not made until several hours after the incident, well beyond the two-hour requirement. The delay was attributed to a busy shift and a misunderstanding about which shift was responsible for making the notification. Interviews with staff, including the CNA, LVN, RN supervisor, and the administrator, confirmed the timeline of events and the failure to report the allegation promptly. The facility's policy clearly required immediate reporting of abuse allegations, but this protocol was not followed, resulting in a delay in notifying the appropriate authorities about the alleged verbal abuse.