Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
A deficiency occurred when the facility failed to initiate an investigation into an allegation of abuse involving a resident with a history of coronary artery disease, heart failure, diabetes, cerebrovascular accident, and non-Alzheimer's dementia. The resident, who was cognitively intact and independent in daily activities, reported that a CNA called him an "ass" during an interaction about another resident's disruptive behavior. The resident stated he reported the incident to the DON, who attempted to minimize the situation, suggesting the CNA may not have meant anything by the comment. The resident expressed dissatisfaction with the response and noted that no one had asked him for a statement regarding the incident. Interviews with the CNA confirmed the use of the term and an apology was made to the resident. However, the Administrator was unaware of the incident, and the DON admitted to not initiating a formal investigation, not collecting statements from involved parties, and not documenting the event as required by facility policy. The facility's policy mandates that all allegations of abuse be thoroughly investigated, but this process was not followed in this case.
Plan Of Correction
F610 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to follow Ohio Resident Abuse Policy and ensure an investigation was initiated for an allegation of abuse affecting resident #24. Step 1: Alleged perpetrator was suspended on 6/4/25 pending investigation results. Resident #24 was assessed and no negative findings. Assessment completed on 6/11/25 by NP with no negative findings. Step 2: To identify other residents that have the potential to be affected, on 6/6/25 the Social Services initiated interviews of those residents able to be interviewed regarding abuse, completing the interviews on 6/6/25 with no negative findings. DON completed skin checks on 6-6-25 for non-verbal and cognitively impaired resident with no negative findings. Step 3: RDCS educated NHA and DON on reporting of all allegations of abuse on 6-6-25. To prevent this from recurring, NHA started immediate in-house education with all staff regarding Abuse Policy and the investigation of all allegations of abuse. Education will be completed by 6/6/25. New hired staff will be educated on abuse policy during orientation. Step 4: NHA/designee will monitor compliance of investigating allegations of Abuse, Neglect, Misappropriation weekly X4 then monthly x2. The results of the audits will be submitted to the QAPI committee for further review and recommendations.