Failure to Assess Psychosocial Harm After Verbal Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse investigation policy by not providing psychosocial assessments for vulnerable, cognitively impaired residents after an allegation of staff-to-resident verbal abuse. The incident involved a staff member using inappropriate language toward a resident, which was reported to the state. During the investigation, the facility conducted staff re-education, staff interviews, interviews of cognitively intact residents, and skin assessments, but did not include psychosocial evaluations for non-verbal or cognitively impaired residents as required by policy. Specifically, three residents with significant cognitive impairments and diagnoses such as dementia, anxiety, depression, and schizophrenia did not receive psychosocial assessments during the investigation period. These residents were not interviewable at the time of the survey, and their clinical records lacked documentation of any evaluation of their psychosocial status following the alleged abuse. The facility's policy required observation and documentation of behavior, affect, and response to interaction for such residents, but this was not completed.