Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an incident of verbal abuse involving two residents within the required two-hour timeframe, as outlined in its own policy and procedure for reporting and investigating abuse. The incident occurred when one resident, who had a history of impulse disorder, dementia, and mood disorder, yelled profanities and a racial slur at another resident with dementia, restlessness, agitation, and anxiety disorder. The resident who was the target of the abuse appeared visibly scared and emotionally distressed during the event, as observed by staff. Despite the severity of the language used, including a racial slur and profanity, the incident was not reported immediately to the Administrator or the Director of Nursing. Both the Administrator and the DON confirmed in interviews that they had not been made aware of the incident and emphasized that such events should be reported right away according to facility policy. The staff member who witnessed the incident admitted to not reporting it as thoroughly as required, only mentioning there was yelling to another nurse without specifying the details of the abuse. A review of the facility's policy confirmed that all allegations of abuse, including verbal abuse, must be reported to the Administrator and appropriate authorities within two hours if the incident involves abuse or results in serious bodily injury. The failure to report the incident in a timely manner prevented the facility from initiating an immediate investigation and implementing protective measures for the resident who was verbally abused.
Plan Of Correction
F-tag: 609 Reporting of alleged violations Immediate corrective actions: On 05/02/25 - 05/10/25, DON / DSD provided 1:1 in-service/training, and re-education to CNA 8 and CNA 9 about Abuse allegation reporting to the Administrator/DON. Resident 23 is no longer in the facility. Resident 47 was monitored with no signs of emotional distress or psychosocial harm noted. Identification of others at risk: The Administrator conducted rounds on 05/02/25 - 05/10/25 to identify any occurrence of allegation of abuse. No other residents were identified with the same deficient practice. Process to prevent recurrence: On 05/02/25 - 05/10/25, the DON/DSD provided in-services to nursing staff (CNA, LVN, RN) to reinforce the policy of reporting of Abuse, Neglect, Exploitation, or Misappropriation—Reporting and Investigating—with emphasis on the importance of the following: - Immediate reporting of all allegations of abuse (immediately or within 2 hours involving alleged abuse or resulting in serious bodily injury). - Notification of Facility administrator, State law agencies (CDPH, Ombudsman), and local law enforcement. - Responsible party, attending physician, and facility's medical director. Monitoring process: The Administrator will conduct random weekly audits on 4-5 residents for 4 weeks and then randomly for 3 months to ensure that residents are free from alleged abuse. The Administrator's findings will be reported to the QAPI committee monthly for further recommendations and resolutions for 3 months or until no negative trends are found. Completed date: 5/20/2025