Failure to Immediately Report Alleged Verbal Abuse of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy regarding the immediate reporting of alleged resident abuse. Specifically, a Hospice CNA reported to Nurse #1 that while two CNAs were providing care to a cognitively impaired resident, one of the CNAs used profane language directed at the resident. Despite being informed of the allegation, Nurse #1 did not immediately notify her direct supervisor, the Executive Director, or the Director of Nursing as required by facility policy. Instead, the incident was not brought to the attention of facility administration until the following day, after the Unit Manager learned of the situation from one of the involved CNAs. The resident involved was cognitively impaired, with documented deficits in memory and decision-making skills. The failure to promptly report the allegation of verbal abuse delayed the facility's awareness and response to the incident, contrary to established procedures designed to protect residents from abuse, neglect, and mistreatment. The deficiency was identified through interviews and record reviews, which confirmed that the required chain of reporting was not followed in this instance.