Failure to Immediately Report and Respond to Allegation of Verbal Abuse
Penalty
Summary
A deficiency occurred when the facility failed to implement its written policies and procedures to prohibit and prevent verbal abuse, resulting in a resident not being protected from such abuse by a registered nurse. The incident involved a resident with chronic kidney disease, anemia, chronic congestive heart failure, and dementia, who was assessed as having severely impaired decision-making abilities. During the early morning hours, a certified nursing assistant overheard a registered nurse making inappropriate and verbally abusive remarks to the resident during toileting care. The certified nursing assistant immediately reported the incident to an LPN, who did not escalate the allegation to the nursing home administrator, director of nursing, or director of social services until the end of the shift. As a result of the delayed reporting, the registered nurse continued to work the remainder of the shift, providing care and passing medications to other residents, which allowed for the possibility of further incidents of verbal abuse. The facility's policy required immediate reporting of abuse allegations to the appropriate administrative staff, but this was not followed. The surveyor confirmed through interviews and record reviews that the LPN was aware of the allegation at approximately 4:30 AM but did not notify the required personnel until after the shift ended, and the registered nurse was not removed from resident care areas until then. Further review revealed that the facility did not collect or investigate statements from all staff present during the shift, which could have provided additional information or identified a pattern of abusive behavior by the registered nurse. The director of social services confirmed that some staff statements were not submitted to the state survey agency, considering them hearsay. The incident left both the resident and the reporting certified nursing assistant visibly distressed, and the facility did not immediately place the resident on the follow-up report board for monitoring after the allegation was made.