Failure to Notify Physician and Representative After Verbal Abuse Incident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was protected from verbal abuse and that appropriate notifications were made following an incident. A certified nursing assistant (CNA) was reported by a roommate to have loudly used inappropriate language, specifically saying 'shut the fuck up,' while providing care to a resident who was on hospice and had severe cognitive impairment. The incident was overheard by the roommate, who then reported it to the Assistant Director of Nursing (ADON). The resident involved was dependent on staff for most self-care needs, had a BIMS score of 00 indicating severe cognitive impairment, and was unable to communicate effectively due to her condition and hearing impairment. Following the report of the incident, there was no documentation that the resident's attending physician or representative was notified, as required by facility policy. Interviews with staff, including the Director of Nursing (DON), ADON, and a Licensed Vocational Nurse (LVN), confirmed that the incident was reported internally but not communicated to the resident's family or physician. The resident's family member, who visited daily, stated she was not informed of the incident by the facility and only learned of it through the survey process. The social worker was also unaware of any facility report involving the resident. Record review and staff interviews further revealed that the facility's policy required immediate notification of the physician and family in the event of a significant change in status, but this protocol was not followed in this case. The roommate who reported the incident did not observe any changes in the resident's behavior following the event, and there was no documentation of any changes in medication or care. The failure to notify the appropriate parties after the incident constituted a deficiency in protecting the resident from abuse and ensuring proper communication as outlined in facility policy.