Failure to Timely Report Alleged Staff-to-Resident Verbal Abuse
Penalty
Summary
Facility staff failed to promptly report incidents of alleged staff-to-resident verbal abuse involving two residents, as required by facility policy and state regulations. In the first case, a resident with chronic respiratory failure, schizophrenia, and moderately impaired cognition was subjected to a comment by a CNA who called the resident 'crazy' for talking to himself. The incident was witnessed by another CNA who was in training but did not report the event immediately, despite having received abuse training during orientation. The incident only came to light during an investigation into a separate abuse allegation involving the same CNA and another resident. In the second case, a resident with severe cognitive impairment and multiple neurological diagnoses was allegedly verbally abused by a CNA during a care interaction. Another CNA, who was being trained by the alleged abuser, witnessed the event but did not report it at the time. The witness later disclosed the incident only when questioned during an unrelated abuse investigation. The witness expressed concerns about retaliation and lack of confidentiality, which contributed to the delay in reporting. In both cases, the facility's own investigative documents and staff interviews confirmed that the required immediate reporting to the administrator and appropriate authorities did not occur. The facility's policy mandates that all allegations of abuse be reported within two hours if abuse is involved, but this protocol was not followed. The deficiencies were identified through record reviews and staff interviews, which revealed lapses in timely reporting and adherence to established abuse reporting procedures.