Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of verbal abuse involving a resident who experienced a fall while attempting to brush his teeth. After the fall, the resident and his family reported that a nurse and CNA yelled at him for self-transferring, removed his call light, water, and bedside table, and shut his door, preventing him from seeking further assistance. Multiple staff statements corroborated that the nurse and CNA verbally abused the resident and took away his means to call for help, with one staff member noting that the doors were closed for all residents at risk of falling. The incident was reported by the resident's family through grievance forms, which were received by staff and reportedly forwarded to the appropriate administrator. Despite facility policy requiring all alleged violations of abuse to be reported to the Administrator and State Survey Agency within specified timeframes, the administrator stated he had no knowledge of the incident or grievances. The abuse was not reported to the State Survey Agency as required, and no Facility Reported Incident was submitted until the surveyor brought the matter to the administrator's attention. Review of the reporting portal confirmed that the required report was not made in a timely manner.