Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to immediately report an allegation of verbal abuse involving a resident with complex medical and behavioral needs, including autism, fetal alcohol syndrome, epilepsy, and tachycardia. The incident occurred when a nurse engaged in a verbal altercation with the resident, using derogatory language, making inappropriate gestures, and escalating the situation in the presence of other staff, residents, and a police officer. The nurse made statements such as 'Y'all need to take her ass somewhere,' 'Her [family member] needs to come get her,' and 'You don't scare me none,' and also flipped off the resident, which further agitated the resident and led to a confrontation that required staff and police intervention to prevent escalation. Multiple certified nursing assistants (CNAs) and other staff witnessed or were aware of the incident but failed to report the abuse to the administrator or the Director of Nursing (DON) as required by facility policy and state law. Interviews revealed that staff were trained on abuse and neglect reporting procedures, but several CNAs assumed others would report the incident or delayed reporting due to absence of the DON or other reasons. As a result, the administrative staff, including the DON, were not made aware of the incident until it was brought to their attention by surveyors two weeks later. The failure to report the incident immediately prevented timely investigation and intervention by facility leadership. The nurse involved continued to work multiple shifts following the incident, and the lack of prompt reporting compromised the facility's ability to ensure resident protection and oversight. The deficiency was identified as Immediate Jeopardy due to the risk posed to residents' safety and well-being.