Failure to Immediately Report Potential Verbal Abuse Incident
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's abuse prevention and reporting policy after an incident involving a resident who was alert, oriented, and able to communicate needs. During a therapy session, an Occupational Therapist (OT) and a Physical Therapist Assistant (PTA) were present with the resident, who had diagnoses including multiple sclerosis, schizoaffective disorder bipolar type, stimulant use, and mild cognitive impairment. The PTA interrupted a conversation between the OT and the resident, leaned forward, and loudly told the resident to "Get off the drugs" before leaving the area. The OT witnessed this interaction and felt it was unprofessional, but did not immediately report the incident to facility administration as required by policy. Instead, the OT waited approximately three weeks before disclosing the incident to the Director of Rehabilitation (DOR) during a meeting. The DOR then informed the OT that the incident should have been reported immediately to the Administrator or Director of Nursing (DON). The OT acknowledged awareness of the facility's abuse policy and admitted to not following the required reporting procedures. The delay in reporting meant that administration was not made aware of the potentially abusive interaction until several weeks after it occurred, constituting a failure to implement and follow established abuse prevention and reporting protocols.