Failure to Immediately Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that an alleged incident of verbal abuse was reported immediately, as required by policy, for one resident with severe cognitive impairment and multiple psychiatric diagnoses. An LVN overheard a CNA verbally abusing the resident and wrote a witness statement, which she placed under the Administrator's door while he was out of the building. The Administrator, who was also the facility's abuse coordinator, did not receive the statement and was not made aware of the allegation until later interviews. The LVN did not follow up or attempt to contact the Administrator by phone or other immediate means, as required by the facility's abuse reporting policy. The resident involved was nonverbal and unable to respond to questions due to severe cognitive impairment. The facility's policy required immediate verbal reporting of suspected abuse to the Administrator or designee, including after hours, but this was not followed. The Administrator confirmed that staff were expected to report abuse allegations directly and immediately, typically by phone or text, to ensure resident safety. The failure to report the allegation in a timely manner resulted in a delay in the facility's awareness and response to the alleged abuse.