Failure to Prevent and Report Verbal Abuse of Resident by LVN
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting and preventing abuse, resulting in a resident not being free from abuse. A female resident with a history of autistic disorder, fetal alcohol syndrome, epilepsy, and other complex medical needs was subjected to verbal abuse by an LVN. The incident occurred in the presence of other staff, residents, and a police officer, and included the LVN making disparaging remarks, using obscene gestures, and escalating the situation with the resident. The LVN made statements such as 'Y'all need to take her ass somewhere,' 'Her family member needs to come get her,' and 'She needs to go to jail,' while also flipping off the resident and inviting her to physical confrontation. The resident became visibly upset, threatened to punch the LVN, and was further agitated by the LVN's continued comments and gestures. Multiple staff members, including CNAs and other nurses, witnessed the incident but did not report the abuse to the Director of Nursing (DON) or the abuse coordinator as required by facility policy. Interviews revealed that staff assumed others would report the incident, or were unsure of the reporting process, despite having received training on abuse and neglect. The DON and administration were unaware of the incident until informed by surveyors two weeks later. The LVN involved continued to work shifts at the facility after the incident, as the administration had not been notified and no investigation was initiated at the time. The failure to report and address the abuse resulted in the resident not being protected from further abuse, and the administration remained unaware of the situation until external intervention. The incident was corroborated by police body camera footage, staff interviews, and resident accounts. The facility's lack of timely response and failure to follow abuse prevention and reporting protocols led to the identification of Immediate Jeopardy by surveyors.