Failure to Ensure Staff Competency in Recognizing and Reporting Verbal Abuse
Penalty
Summary
Facility staff failed to ensure that Certified Nurse Assistants (CNAs) possessed the necessary competencies to recognize and respond to verbal abuse, as required by facility policy. On the date of the incident, one resident with a history of impulse disorder, dementia, and mood disorder was observed in a heightened emotional state, yelling a racial slur and profanity at another resident who has dementia, restlessness, agitation, and anxiety disorder. The second resident, who has severely impaired cognition and requires moderate assistance with activities of daily living, was visibly frightened and attempted to move away from the situation. Interviews revealed that CNA 8 was present but did not hear the abusive language, although aware of the resident's history of such behavior. CNA 9, who was also present, acknowledged hearing the loud and aggressive statements and attempted to de-escalate the situation but did not report the incident as required. Both the Administrator and Director of Nursing were not notified of the incident at the time, contrary to facility policy, which mandates immediate reporting of abuse allegations to supervisory staff for investigation and state reporting if necessary. The facility's policies define verbal abuse as any use of disparaging or derogatory language within hearing distance of residents and require immediate reporting of suspected abuse. The Director of Staff Development later identified a need for reinforcement of abuse reporting protocols among staff, noting that delayed reporting could allow further incidents to occur and negatively impact residents' well-being.
Plan Of Correction
F-tag: 726 Competent Nursing Staff Immediate corrective actions: On 05/02/25, DON / DSD provided 1: - in-service/training, and re-education to CNA 8 and CNA 9 regarding policy for Abuse reporting with emphasis on the importance of: - How to recognize verbal abuse on residents. - Implement the facility's policy on abuse. - Immediately report any alleged abuse to the Administrator/DON for further investigations and reporting. Identification of others at risk: The Administrator conducted rounds on 05/02/25 and 05/10/25 and interviewed: - nursing staff (CNA, LVN, RN) on how to recognize verbal abuse and state the facility's policy of abuse. No other staff were found with the same deficient practice. Process to prevent recurrence: In-services were given by the Administrator on 05/02/25 through 05/10/25 and 05/20/25 to reinforce the policy of Abuse reporting. Monitoring Process: The Administrator will conduct random weekly interviews of facility staff and residents to reinforce the policy of Abuse with emphasis on recognizing abuse, implementing policy on abuse, and immediate reporting for 3 months. Identification of others at risk: The Administrator conducted rounds on 05/02/25 and 05/10/25 and interviewed: - nursing staff (CNA, LVN, RN) on how to recognize verbal abuse and state the facility's policy of abuse. No other staff were found with the same deficient practice. Process to prevent recurrence: In-services were given by the Administrator on 05/02/25 through 05/10/25 and 05/20/25 to reinforce the policy of Abuse reporting. Monitoring Process: The Administrator will conduct random weekly interviews of facility staff and residents to reinforce the policy of Abuse with emphasis on recognizing abuse, implementing policy on abuse, and immediate reporting for 3 months. The Administrator's findings for abuse/allege reporting will be presented to the monthly QAPI committee for further recommendations and resolutions for 3 months. Completed date: 5/20/2025 F 726