Failure to Timely Report Alleged Verbal Mistreatment of a Resident
Penalty
Summary
The facility failed to ensure that an alleged violation involving verbal mistreatment of a resident was reported immediately, but not later than 2 hours after the allegation was made, as required. A resident with a diagnosis of Type II Diabetes Mellitus and prescribed insulin reported that, during a hypoglycemic episode, he requested food from a nursing aide and was told, "There are no sandwiches, shut up and go to sleep!" The resident expressed distress over the incident. Documentation shows that the resident experienced hypoglycemia, with a blood glucose reading of 40 mg/dl, and that the incident was brought to the attention of nursing staff. However, the initial report to the Office of Health Facility Licensing and Certification (OHFLAC) was not submitted until several days after the incident, exceeding the mandated reporting window for abuse allegations. Record review revealed that the facility was aware of the circumstances surrounding the incident on the same day it occurred, as evidenced by new dietary and insulin orders placed in response to the resident's hypoglycemic episode. Despite this, the facility did not report the allegation of verbal mistreatment to the appropriate authorities within the required timeframe. The delay in reporting was confirmed through interviews and documentation, with the Assistant Director of Nursing stating she was not aware of the details until days later, despite evidence to the contrary in the medical record.