Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, as required by regulation. Specifically, a staff member (Confidential Staff C) witnessed another staff member (CNA B) allegedly call a resident 'pissy and smelly' during a heated argument but did not report the incident to the Administrator or Abuse Coordinator. Confidential Staff C stated that previous reports to administration about CNA B had not resulted in action, which contributed to the failure to report this new allegation. The facility's policy requires immediate verbal reporting of suspected abuse to the Abuse Preventionist or designee, but this procedure was not followed in this instance. The resident involved was an elderly female with diagnoses including dementia, hypertension, and chronic obstructive pulmonary disease. Her quarterly MDS assessment indicated she was usually understood and had intact cognition, with a BIMS score of 15. She required moderate assistance for toileting hygiene and was frequently incontinent. Her care plan included interventions for incontinence and resistive behaviors, with specific instructions for staff to report incidents of care refusal to the charge nurse. Interviews with facility leadership, including the DON and Administrator, confirmed that the alleged verbal abuse was never reported to them. Both emphasized the importance of immediate reporting to protect residents and stated that the facility provided regular in-services on abuse prevention and reporting. The resident herself did not recall any staff making mean comments, but the failure to report the allegation as required constituted a deficiency in the facility's abuse reporting procedures.