Failure to Immediately and Accurately Report Alleged Abuse
Penalty
Summary
The facility failed to immediately and accurately report an allegation of emotional/verbal abuse involving a resident with schizoaffective disorder, generalized anxiety disorder, obsessive-compulsive disorder, delusional disorders, and dementia, who was cognitively intact at the time of the incident. The incident involved an LPN who spoke to the resident in a manner that made her feel uncomfortable, including taking her down the hallway and telling her it was none of her business to speak about the LPN to other staff. The resident reported feeling uncomfortable, and staff statements described the LPN's actions as intimidating and embarrassing, including snatching a juice cup and scolding the resident for coming out of her room to get juice. Multiple staff and resident statements described a hostile and uncomfortable environment during the incident, with the LPN's behavior being characterized as aggressive and dismissive. Other residents and staff witnessed the LPN's actions, and one CNA described the behavior as abusive. Despite these observations, the facility's investigation concluded that abuse did not occur, based on interviews and assessments that found no negative outcomes for the resident or others involved. The facility's reporting process was flawed, as the self-reported incident (SRI) was not submitted immediately, and the wrong staff member was listed as the alleged perpetrator in the SRI. The narrative in the SRI was also inaccurate, as it included information from another incident. The delay in reporting and inaccuracies in the documentation were confirmed by facility leadership, who acknowledged that the allegation was not reported immediately and that the SRI did not accurately reflect the incident or the correct staff member involved.