Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse involving a resident and a staff member were thoroughly investigated. The resident, who had multiple medical diagnoses including dementia, anxiety disorder, and major depressive disorder, was documented as cognitively intact and able to make reasonable decisions. Multiple certified nursing assistants (CNAs) and another resident reported that the resident had complained about an LPN being verbally abusive, using phrases such as "you are crazy" and "it's all in your head." The resident was visibly upset and reported being afraid of the staff member in question. Despite these reports, there was no documentation of a care plan focus area related to abuse or behaviors for this resident. Several staff members, including CNAs, stated that they either reported the allegations to the administrator or the director of nursing, or advised the resident to do so. However, both the administrator and the director of nursing stated they were unaware of any specific allegations of verbal abuse involving the staff member and the resident. The director of nursing recalled being told the resident was upset but did not receive details or the name of the alleged perpetrator. A grievance form was filed by the resident, indicating a staff concern, but lacked specific details about the incident. Follow-up documentation regarding the grievance was incomplete, with only one progress note available and no evidence of the required weekly follow-up meetings. The facility's abuse prevention policy requires immediate reporting and thorough investigation of alleged violations, with specific steps to prevent further abuse during the investigation. However, the investigation into the allegations was only initiated after the state surveyor brought the issue to the attention of the administrator and director of nursing. By that time, both the staff member accused and the resident had already been discharged. The lack of timely and thorough investigation, incomplete documentation, and failure to follow policy requirements led to the deficiency.