Failure to Immediately Report Alleged Verbal Abuse
Penalty
Summary
An allegation of verbal abuse was made against a registered nurse (RN) who was reported to have made inappropriate comments to a resident during toileting assistance in the early morning hours. The certified nursing assistant (CNA) who overheard the comments immediately reported the incident to the licensed practical nurse (LPN) on duty. However, the LPN did not immediately escalate the allegation to the Nursing Home Administrator (NHA), Director of Nursing (DON), or Director of Social Services (DSS) as required by facility policy. Instead, the LPN waited until the end of the shift to inform the DON, allowing the RN accused of verbal abuse to continue working and have contact with other residents until the shift ended. The resident involved had significant medical conditions, including chronic kidney disease, anemia, congestive heart failure, and dementia, with a severely impaired ability to make daily decisions as indicated by a low BIMS score. The resident required substantial assistance with activities of daily living and was described as typically happy and thankful, making the reported behavior and distress during the incident notable. The incident was documented in the resident's electronic health record, including the resident's emotional distress and statements expressing a wish to die, which were addressed by the RN in the documentation. Interviews with staff confirmed that the LPN was made aware of the alleged abuse at approximately 4:30 AM but did not notify facility leadership until after the shift ended. The RN remained on duty and continued to provide care, including passing medications, until leaving the facility at the end of the shift. The delay in reporting the allegation was contrary to the facility's written policies, which require immediate reporting of abuse allegations to the appropriate authorities to ensure resident protection and compliance with regulatory requirements.