Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported to the appropriate authorities within the mandated timeframe. A resident (R5), who was cognitively intact and had diagnoses including diabetes, hypertension, restlessness, and agitation, reported that her former roommate (R6), also cognitively intact with diagnoses of bipolar disorder and schizophrenia, verbally threatened her in a confrontational manner. The incident involved R6 approaching R5 on the porch and stating, 'I'll beat your mother f*****g a**,' which R5 perceived as a vicious and unprovoked verbal assault. Following the incident, R5 reported the threat to the facility's security guard (V6), who documented the event in the Security Report and stated he informed the administrator (V1) and a nurse on the first floor. However, both the LPN (V7) and CNA (V8) working that shift denied being informed of any unusual events or allegations of verbal abuse. The administrator (V1) acknowledged receiving a call from security but did not recognize the urgency or nature of the report as verbal abuse at that time. The initial report to the state agency was not made until several days later, after V1 received the information in real time, rather than immediately as required by facility policy and regulation. Documentation confirmed that the incident was later substantiated as abuse, with both internal and external reports indicating that the verbal threat constituted verbal abuse. Facility policy requires immediate reporting of any abuse allegations to the Department of Public Health within 24 hours, but this protocol was not followed in this case, resulting in a delay in the mandated reporting process.