Failure to Notify Resident's Representative of Verbal Abuse Allegation
Penalty
Summary
The facility failed to notify a resident's representative of an allegation of verbal abuse involving a racial slur made by a staff member. The incident was reported to the Director of Nursing (DON) by a Certified Nursing Assistant, who stated that an LPN had used inappropriate language referencing a racial slur while recounting an interaction with the resident. The DON acknowledged that the language was inappropriate and addressed it with the staff member involved. However, the DON did not inform the resident's Power of Attorney (POA) about the incident at the time, stating that she did not believe notification was necessary since the allegation was not directed toward the resident. Upon further review, the DON recognized that the incident constituted an allegation of verbal abuse and that facility policy required notification of the resident's representative. The resident involved had diagnoses including dementia, age-related osteoporosis, and a history of falls, with a documented Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. The facility's records, including progress notes and the initial reportable event documentation, did not show any evidence that the POA was notified of the verbal abuse allegation. The facility's abuse policy specifically requires informing the resident's representative of any report of potential mistreatment and ongoing investigations, which was not followed in this case.