Failure to Immediately Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to implement its policies and procedures for the immediate reporting of alleged abuse to the State Agency for one resident. A cognitively intact resident reported that a certified nurse aide (CNA) verbally abused him by yelling after he had a bowel movement accident. The resident stated he reported the incident to facility staff, including a nurse who witnessed the event and encouraged him to report it, as well as to the social worker and facility leadership. The resident also indicated he had previously reported similar concerns about the same CNA, and management had stated they would address it. Interviews with staff confirmed that the resident's complaint was discussed among the nursing home administrator, social workers, and nursing supervisor. The staff acknowledged that the resident expressed feeling unsafe with the CNA and that other residents had also complained about the same CNA in the past. The nurse who witnessed the incident described the CNA's tone as condescending and reported intervening to deescalate the situation. However, documentation of the investigation was limited, and there was no evidence that interviews with other residents or staff were conducted to verify that abuse did not occur. Review of facility policy revealed that alleged violations involving abuse must be reported immediately to the State Agency within two hours. Despite this requirement, the incident was not reported as mandated. Instead, the facility handled the complaint internally, documenting it in a clinical note and making changes to the resident's care assignment, but failed to follow the required external reporting procedures.