Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident was reported to the State Survey Agency within the required two-hour timeframe after the allegation was made known to facility administration. According to facility policy, any suspicion or allegation of abuse must be reported immediately to the administrator, who is then responsible for notifying the appropriate authorities within two hours if the incident involves abuse. In this case, a CNA reported to nursing staff that another CNA had used foul and derogatory language toward a resident with severe cognitive impairment. The incident was initially reported to the assigned nurses at the time it occurred, but the required incident report and subsequent notification to administration were delayed. The resident involved had significant cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's disease, schizophrenia, and major depressive disorder, rendering her unable to participate in interviews. The alleged verbal abuse occurred during a shift change, and although staff members reported the incident to the appropriate nurses, the process for completing the incident report and escalating the matter to administration was not followed promptly. The administrator and DON were not informed until two days after the incident, at which point the accused CNA was suspended pending investigation. Despite being made aware of the allegation, the administrator did not enter the required report into the SIMS system within the mandated two-hour window. The initial attempt to submit the report was delayed, and technical issues further postponed the entry, resulting in the report being filed several days after the facility became aware of the incident. Interviews with staff confirmed that the facility's policy required immediate reporting, and the administrator acknowledged that the report was not submitted within the required timeframe due to competing priorities at the facility.