Failure to Timely Report Alleged Verbal Abuse and Mistreatment
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse by a staff member toward a resident to the appropriate management staff, as required by facility policy and regulatory requirements. The incident involved a resident with mild cognitive impairment and multiple behavioral and mental health diagnoses, who was found on the floor by a CNA. The LPN on duty responded and made belittling and derogatory comments to the resident during the assessment and transfer back to bed. The CNA present reported that the LPN's tone was inappropriate and that the comments included disparaging remarks about the resident's fall, physical appearance, and decision-making. The CNA did not immediately report the incident, stating he was unsure of the reporting process at the time and waited until the next day to notify management. The facility's policy required that any employee or agent who becomes aware of abuse or neglect immediately report the matter to the Administrator or their designee, and that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the Administrator and the mandated state agency within two hours. However, the report of the incident was delayed, and the required notification to management and authorities was not made within the specified timeframe. Staff interviews confirmed that there was a lack of clarity among some staff regarding the reporting protocol, and that education on the abuse protocol and reporting timeframes was subsequently provided. Additionally, there were reports from another resident regarding a different staff member, an agency CNA, who was alleged to have used discriminatory language and refused to assist with care. Multiple staff members acknowledged hearing complaints from the resident about this CNA, but did not recall reporting these concerns to administration, often attributing the complaints to the resident's general dissatisfaction. The DON and Administrator both stated that all suspected abuse should be reported for investigation, regardless of the resident's history of complaints.