Failure to Timely Report Staff-to-Resident Verbal Abuse
Penalty
Summary
A staff-to-resident verbal abuse incident occurred involving a resident with schizophrenia and unspecified dementia, who was dependent on staff for personal hygiene and required substantial to maximal assistance for mobility. During care, a CNA was witnessed by two other CNAs yelling and using demeaning, derogatory, and profane language directed at the resident. The incident was observed by the two CNAs, who documented the event in written statements but did not immediately report the abuse to the charge nurse on duty. The written statements were left under the doors of the administrator and DON, but were not discovered until approximately two days after the incident. During this period, the alleged perpetrator continued to work and had further contact with the resident. The charge nurse on duty did not receive a direct report of the abuse, and other staff members who were aware of the written statements did not inquire further or escalate the report to administration as required by facility policy. Facility policy and federal and state regulations require that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made, especially if the event involves abuse or results in bodily injury. In this case, the delay in reporting resulted in the State Agency not being notified until at least 40 hours after the occurrence of the alleged abuse. The failure to follow established reporting protocols led to a deficiency finding during the survey.