Failure to Investigate Alleged Verbal Abuse and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a registered nurse and a resident with severe cognitive impairment. The incident occurred when a certified nursing assistant overheard the nurse making inappropriate comments to the resident during early morning care. The certified nursing assistant immediately reported the incident to an LPN, who did not escalate the report to facility leadership until the end of the shift, allowing the alleged perpetrator to continue working and have contact with other residents. The nurse was not immediately removed from resident care areas, contrary to facility policy. The investigation into the incident was incomplete. Statements from three staff members who were present during the shift were not collected or submitted to the state survey agency, and the facility did not follow up on these missing statements. Additionally, the facility did not update the resident's care plan to address any psychosocial issues that may have arisen from the incident. The director of social services did not notify the resident's psychologist about the resident's expressions of distress, including statements about not wanting to live, which were documented in the medical record but not communicated to the appropriate mental health professional. The resident involved had a history of chronic kidney disease, anemia, congestive heart failure, and dementia, with a severely impaired mental status and dependence on staff for most activities of daily living. At the time of the incident, the resident had recently experienced a decrease in antidepressant medication and was noted to be more confused and anxious. Despite these changes and the resident's expressions of emotional distress following the alleged verbal abuse, there was no documented follow-up or emotional support provided, and the facility did not ensure that all required investigative and protective actions were taken as outlined in their own policies.