Failure to Timely Report Alleged Verbal Abuse to Administrator
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse were reported to the Administrator or Abuse Coordinator as required by policy. A resident with multiple medical conditions, including dementia, anxiety disorder, and major depressive disorder, reported to a CNA that an LPN had yelled at her and made derogatory remarks, causing the resident to become visibly upset and cry. The CNA did not report the allegation to the Administrator, stating she did not witness the incident and advised the resident to report it herself. The resident also reported similar concerns to another CNA on multiple occasions, who stated she did report it to the Administrator and Director of Nursing, but both denied awareness of any such allegations. The resident documented the alleged verbal abuse on a piece of paper, which included statements such as "choke on that," "it's all in your head," and "you are crazy," but did not include dates or times. Despite the facility's policy requiring immediate reporting of abuse allegations to the Administrator, the incident was not reported or investigated until a state surveyor brought it to the attention of facility leadership. Interviews with staff revealed inconsistent reporting and a lack of documentation or care plan focus related to abuse or behaviors for the resident. The Director of Nursing recalled staff mentioning the resident was upset with a staff member but did not recall any specific abuse allegations. The Administrator only became aware of the situation after being informed by the surveyor, at which point an investigation was initiated.