Failure to Report Alleged Verbal/Emotional Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of verbal/emotional abuse involving a resident was reported to the State survey agency as required. The incident involved a resident with multiple diagnoses, including metabolic encephalopathy, bipolar disorder, malignant neoplasm of the uterus, adult failure to thrive, and depression. On the day of the incident, the resident experienced a significant change in condition and was found unresponsive, leading to her transfer to the hospital for evaluation and treatment of sepsis and acute kidney injury. During the assessment of the resident's change in condition, a CNA witnessed an LPN make an inappropriate comment with sexual innuendo while checking the resident's hand grasp strength. The CNA felt uncomfortable with the comment and reported it to the unit manager, who instructed her to provide a written statement. The CNA completed the statement and left it in the unit manager's office as directed. The unit manager confirmed receiving the report and informed the DON about the situation, acknowledging that the comment could be considered verbal/emotional abuse if it had occurred. Despite the report being made, the DON did not receive the written statement and did not initiate an investigation or report the allegation to the State survey agency. The DON stated that she did not initially interpret the incident as potential abuse, partly due to the resident's unresponsiveness at the time. The facility's abuse prohibition policy requires immediate reporting and investigation of all abuse allegations, regardless of the resident's ability to comprehend. However, no self-reporting incident was submitted, and the required procedures for handling abuse allegations were not followed.