Failure to Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the State Agency as required by its own abuse policy and federal and state law. The facility’s policy on Abuse, Neglect and Misappropriations, revised 1/1/2025, states that all alleged violations involving abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property must be investigated and reported immediately, defined as no later than two hours after the allegation is made, to the Facility Administrator, the State Survey Agency, and other appropriate agencies. Verbal abuse is defined in the policy as the use of oral, written, or gestured language that includes any threat or frightening, disparaging, or derogatory language to residents or their families, or within their hearing distance. Staff interviews confirmed their understanding that verbal abuse allegations are reportable and must be reported within two hours. The resident involved, R11, had diagnoses including metabolic encephalopathy, depression, generalized muscle weakness, and anxiety disorder, and was care planned for fall risk and behavior related to refusing care. A recent MDS showed a BIMS score of 15, indicating she was cognitively intact, with documented depression symptoms and significant functional dependence for multiple ADLs, including toileting, bathing, and transfers. On the morning after a reported fall, an LPN documented that the resident stated she had fallen overnight, hit her side table and then the floor, and that a nurse found her on the floor and instructed her to get up. The LPN observed redness to the resident’s left eye and reported these observations to management. Subsequent progress notes documented that the DON and Unit Manager spoke with the resident and her sister about the incident, and that the resident gave differing accounts of what happened and refused further evaluation and interventions. Interviews and documentation showed that R11 alleged that a night-shift nurse cursed at her in connection with the fall. LPN GG reported that during shift change rounds, the resident stated she had fallen off the bed, hit her head, and that the night nurse told her to get the “curse-word” up. UM FF confirmed that she was notified by LPN GG that the resident reported being cursed at by the night nurse and that she then notified the DON. UM FF defined verbal abuse as being spoken to harshly and acknowledged knowing that abuse allegations must be reported to the state within two hours. The DON stated that when he spoke with the resident, she initially said the staff told her to get the “curse word” off the floor, then changed her account to say the staff only told her to get out of bed after he informed her he would have to report the incident, and then returned to her original statement. The DON and the Abuse Coordinator/AIT both confirmed that the allegation was not reported to the State Agency because the resident changed her story, despite the facility policy requiring immediate reporting of all abuse allegations and staff acknowledging that verbal abuse is reportable. Further interviews with the resident and her family corroborated that the resident reported being cursed at by staff. The resident described the alleged perpetrator as a tall, slender Black man in a high position at the facility and identified him as the DON, and she told the surveyor that this person had cursed her and her sister because he wanted her to leave. A family member stated that the resident told her she had fallen and that the nurse had cursed at her. The Abuse Coordinator confirmed that the administrator was aware of the incident and that, although he was the abuse coordinator, the administrator determined what would be reported to the state. Despite multiple staff being aware of the allegation of verbal abuse and the facility’s written requirement to immediately report all such allegations to the State Survey Agency, the facility did not report this allegation, resulting in the cited deficiency.
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