Failure to Investigate and Act on Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate and take immediate action following an allegation of verbal abuse by a staff member toward a resident. The incident involved a resident with multiple diagnoses, including bipolar disorder, schizoaffective disorder, and moderately impaired cognition, who was reported to have been yelled at and threatened by a CNA after repeatedly using her call light. The hospice aide present at the time reported the incident to the facility Administrator and her own supervisor, describing the CNA as speaking aggressively and threatening to take away the resident's call light. Despite this, there was no documentation of the incident in the resident's medical record or nursing notes. Interviews revealed that the CNA continued to work in the facility and was not removed from resident care duties following the allegation. The Administrator confirmed that she was aware of the report but did not initiate a Self-Reported Incident (SRI), did not interview the involved staff or resident, and did not conduct an investigation. The CNA was not provided with education regarding abuse or customer service, and no protective measures were implemented for the resident or other residents on the secure unit. Facility policy required immediate reporting, investigation, and protective actions in response to allegations of abuse, including removing the accused staff member from resident care areas and notifying appropriate authorities. However, these procedures were not followed. The failure to act on the allegation of verbal abuse affected one resident directly and had the potential to impact all residents on the secure unit.