Failure to Investigate and Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for investigating and reporting an allegation of verbal abuse involving one resident. The resident, who had diagnoses including malignant neoplasm of endometrium, malignant neoplasm of cerebral meninges, and dementia, was alert and oriented, and had a care plan addressing behavioral issues such as refusal of care and accusatory behavior toward staff. The resident reported to multiple staff members, including CNAs and an LPN, that she was being treated rudely and subjected to profanity by night shift CNAs. These staff members stated they reported the allegations to nursing staff and administration. The resident also reported the abuse to a hospital social worker during a hospital stay, who then informed the facility and its hospital liaison of the allegations. Despite these multiple reports, facility administrative staff, including the Administrator, DON, and ADON, stated they were unaware of any abuse allegations regarding this resident. Review of facility records and the Ohio Department of Health reporting system confirmed that no Self-Reported Incident (SRI) was filed for this allegation, and no investigation was initiated as required by facility policy. The facility's policy mandates that all abuse allegations be reported to the Administrator, investigated, and reported to the State Survey Agency within five working days, which did not occur in this case.