Failure to Investigate Allegations of Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate multiple allegations of verbal abuse by one resident towards three other residents. Medical record reviews and interviews revealed that the residents involved had various diagnoses, including schizophrenia, congestive heart failure, diabetes, cerebral infarction, major depressive disorder, hypertension, COPD, and alcohol-induced psychotic disorder. Despite being cognitively intact or only moderately impaired, the affected residents reported being subjected to repeated verbal abuse, including profane and offensive language, by another resident. Staff members, including LPNs and CNAs, witnessed these incidents but did not report them due to fear of retaliation or belief that management would not act. Further review showed that the facility had not filed any Self-Reported Incidents (SRIs) or conducted investigations related to these allegations during the relevant period. The facility's own policy requires investigation of all abuse allegations, but interviews with staff and the administrator confirmed that no such investigations had taken place. The administrator was unaware of the recent allegations, and the facility's records did not reflect any action taken in response to the reported verbal abuse.