Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of verbal abuse involving two residents, one of whom had a history of post-traumatic stress disorder related to prior abuse and racial trauma. On the date of the incident, one resident walked past another resident's room, resulting in a verbal altercation where racial slurs were exchanged. The incident was witnessed by an LPN, who intervened after hearing the commotion from another hallway. Documentation shows that the social worker met with both residents the following day to discuss the incident, but the care plan for the resident with a history of trauma was not updated, and there was no further documentation or investigation into the event. The Director of Nursing (DON), who also served as the Abuse Coordinator, determined after a verbal conversation with the LPN that the incident did not constitute abuse and did not initiate an official investigation, submit a Facility Reported Incident (FRI) report, or notify the State Agency, Ombudsman, residents' families, or Medical Director. The facility's policy required that all allegations of abuse be investigated and reported within two hours, including interviews with all involved parties and appropriate notifications. However, the DON did not interview the residents involved or any potential witnesses, and the incident was not documented as an abuse allegation, resulting in a failure to follow established procedures.