Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving two residents and a visitor. According to progress notes and interviews, a visitor reported that the spouse of one resident verbally confronted another resident in the hallway, pointing a finger and using aggressive language, which caused the second resident to become visibly upset and cry. The visitor also noted that the spouse had a history of similar behavior and that the affected resident appeared distressed after the incident. Despite this, there was no documentation in the second resident's medical record regarding the altercation, nor evidence that the incident was investigated as an allegation of abuse. Further review revealed that the incident was not reported to the State Licensing Agency, and no summary of an investigation was sent as required. While the facility did file a report with Adult Protective Services (APS) concerning the interaction between the resident and their spouse, no such report was made regarding the incident involving the second resident. Interviews with the DON and Administrator confirmed that they did not investigate or report the incident as abuse, and were unaware of the requirement to report such allegations to both APS and the State Licensing Agency.