Failure to Timely Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving a resident and a Certified Nurse Assistant (CNA) within 24 hours, as required by its Abuse and Neglect Prohibition Policy. The incident occurred when the resident, who had diagnoses including hypertension and legal blindness and was assessed as having the capacity to understand and make decisions, had an argument with the CNA at the nurses' station. Both the resident and the CNA used indecent language toward each other, and the resident reported that the CNA yelled and made an inappropriate comment. The progress notes documented the altercation but did not indicate that an investigation was initiated. Interviews revealed that the Registered Nurse (RN) present during the incident recognized that yelling at residents could be considered abuse and acknowledged that the incident should have been reported immediately to the Administrator (ADM) for investigation. However, the ADM was not informed of the incident until the following day, resulting in a delay in starting the investigation beyond the 24-hour requirement outlined in the facility's policy. This delay was acknowledged by both the RN and the ADM, and it was noted that the lack of timely investigation could have led to further incidents.