Failure to Report Alleged Verbal and Mental Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency involving two residents. One resident, who was cognitively intact and had diagnoses including borderline intellectual functioning, bipolar disorder, and anxiety, was reported by multiple staff members and another resident to have engaged in verbally aggressive and bullying behavior towards another resident with severe cognitive impairment due to dementia. Incidents included yelling, making threats, mocking, and making derogatory comments in the dining room, which were witnessed by several staff members including CNAs, an activity aide, and a nurse. These behaviors were discussed among staff and in interdisciplinary team meetings, but were not taken seriously or escalated as abuse allegations. Staff interviews revealed that the bullying and verbal aggression were reported to both the Director of Nursing (DON) and the Nursing Home Administrator (NHA) at the time of the incidents. Despite these reports, the DON and NHA did not consider the actions to constitute abuse, as there was no physical contact, use of profanity, or apparent harm. As a result, no report was made to the State Agency as required by facility policy and federal regulations, which mandate immediate reporting of all allegations of abuse, including verbal and mental abuse, regardless of perceived severity or outcome. The facility's own policy defined mental and verbal abuse to include harassment, mocking, insulting, ridiculing, yelling, or threatening behavior, and required immediate reporting of such allegations to the administrator and the State Survey Agency. The failure to report these incidents, despite multiple staff being aware and the behaviors fitting the policy's definition of abuse, constituted a deficiency in the facility's abuse reporting procedures.