Failure to Timely and Thoroughly Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into a reported incident of verbal abuse involving a resident with schizophrenia and unspecified dementia. Two CNAs witnessed another CNA using demeaning and derogatory language, including cursing, while providing personal care to the resident. The CNAs documented the incident and submitted written statements by placing them under the administrator and DON's door. However, the administrator did not discover these statements until two days later, resulting in a delay in initiating the investigation. During this period, the accused CNA continued to work on the dementia unit and had ongoing contact with the resident and others. Upon review, it was found that the administrator did not follow the facility's abuse investigation policy, which required immediate initiation of an investigation, interviews with all involved staff, attempts to interview the resident, and interviews with other residents who had received care from the accused staff member. The administrator did not interview the involved CNAs after reading their statements, did not attempt to interview the resident or other residents on the unit, and did not interview other staff who may have had relevant information. The DON was unaware of the incident until returning from vacation, and some staff were not immediately in-serviced on abuse and neglect following the event. The resident involved was dependent on staff for personal hygiene and mobility, had moderate hearing difficulty, and was rarely understood, according to the most recent MDS. The incident was witnessed by two CNAs, who reported that the accused CNA used harsh and abusive language multiple times. Despite these reports, the facility's response was delayed and incomplete, failing to meet its own policies for abuse investigation and resident protection.