Failure to Timely Report and Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure regarding abuse, neglect, and exploitation by not reporting an allegation of verbal abuse from one resident to another to the required authorities within the mandated timeframe. Specifically, a resident with mild cognitive impairment and total dependence on staff for activities of daily living reported that his roommate had repeatedly yelled at him, used offensive language, and made discriminatory remarks about his race. Multiple certified nursing assistants (CNAs) confirmed hearing these profanities and discriminatory remarks on several occasions, particularly when the resident was watching television. Despite this, none of the CNAs reported the incidents to supervisory staff, assuming that everyone was already aware of the behavior. The Social Services Director (SSD) and other facility leadership, including the Director of Nursing (DON) and the administrator, were unaware of the ongoing verbal abuse until it was brought to their attention during the survey. Interviews revealed that staff did not follow the facility's policy, which requires immediate reporting of all alleged violations of the abuse policy to the administrator, state agency, and other required agencies, no later than two hours after the allegation is made. The SSD and administrator acknowledged that the language used constituted verbal abuse and should have been reported and investigated according to policy. A review of the facility's policy confirmed that verbal abuse includes disparaging and derogatory communication directed at residents or within their hearing, regardless of their ability to comprehend. The policy also specifies that all alleged violations must be reported promptly to ensure resident protection. The failure to report the abuse resulted in unidentified abuse within the facility and a lack of protection for the affected resident.