Failure to Remove Staff After Allegation of Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member and did not follow its own policy regarding the immediate removal of the accused staff member from duty pending investigation. A cognitively intact resident with multiple medical conditions, including vascular dementia and an above-the-knee amputation, was involved in a verbal altercation with a certified nursing assistant (CNA). The CNA was reported to have yelled, pointed a finger, and made threatening and aggressive comments toward the resident, which was witnessed by another CNA. The incident was reported by the witness to the unit manager by phone and through a written report, but the written report could not be located during the investigation. The unit manager acknowledged receiving the verbal report but did not escalate the incident to the Director of Nursing (DON) or the Administrator, and no state report was filed until surveyor intervention. The accused CNA continued to work scheduled shifts after the incident, contrary to facility policy requiring immediate removal of staff accused of abuse. Interviews with the resident confirmed feelings of being threatened and verbally abused. The DON and Administrator were unaware of the incident until informed by surveyors, and no internal documentation or investigation was initiated prior to the survey.