Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of staff-to-resident verbal abuse involving a resident with multiple medical conditions, including osteomyelitis, diabetes with skin complications, traumatic amputation, hyperlipidemia, bipolar disorder, and hypertension. The resident, who was cognitively intact, reported that a dietary staff member used profane language and refused to prepare a requested meal. Multiple staff statements corroborated the resident's account, indicating that the staff member was insubordinate, used inappropriate language, and refused to fulfill meal requests. The incident was promptly reported to the dietary manager and administrator, and the staff member was sent home and subsequently terminated for various offenses, including inappropriate conduct toward a resident and sleeping on duty. Despite the immediate actions taken by the dietary manager, the administrator, who was also the facility's abuse coordinator, did not initiate or complete a formal investigation into the incident as required by the facility's Abuse Prevention Program Policy. The administrator acknowledged awareness of the incident but classified it as a customer service issue rather than potential verbal abuse, and did not review all relevant documentation or conduct interviews beyond reviewing employee discipline paperwork. There was no documentation of the incident in the facility's reportable abuse incidents, and the required investigation steps outlined in facility policy—such as interviewing all involved parties and reviewing the circumstances—were not followed. The lack of a thorough investigation was further highlighted by the dietary manager's resignation, citing an inability to address the abuse situation appropriately due to administrative direction. The administrator's decision not to classify the incident as abuse and not to report it to the state agency resulted in the facility failing to meet its obligation to promptly and aggressively investigate all reports and allegations of abuse, as outlined in its own policy. This deficiency was identified through interviews, record reviews, and the absence of required documentation and reporting.