Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving one resident. The resident, who was moderately cognitively impaired, reported that a CNA used abusive language directed at his mother. Another resident, who was cognitively intact, corroborated the incident, stating that the CNA responded to the resident's offensive term by using inappropriate language about the resident's mother. The resident's family member also reported the incident to the Administrator, along with concerns about the resident being left unattended in the shower room. Despite these reports, the Administrator stated there was no documentation of the verbal abuse allegation, and the concern was not entered into the formal grievance log. The Administrator also indicated he was not previously aware of the verbal abuse allegation. Interviews with facility leadership revealed that the investigation into the allegations was incomplete and ongoing, with attempts to contact the accused CNA still pending. The DON and a Unit Manager interviewed the resident in private, during which the resident described the CNA's behavior, including verbal abuse, kicking the door, and bumping his chair, but could not identify the CNA by name. The DON also stated that the family member's initial report focused on the resident being left in the shower, which was later found to be unsubstantiated upon video review. The lack of thorough investigation and documentation of the verbal abuse allegation constituted the deficiency.