Failure to Timely and Accurately Report Allegations of Verbal Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of verbal abuse and neglect involving one resident. On a specific date, the Activity Director heard someone yelling loudly while in the activity room and heard a staff member state that the resident could not keep pushing the call light unless something was needed because there were other people to care for. When the Activity Director stepped out, she saw a CNA exiting the resident’s room. A similar account was documented by the Activity Assistant, who heard an aide using a very loud and angry tone and heard the aide tell the resident not to keep pushing the call light if she did not need something, because there were other people to take care of and there was no time to keep coming into the room. These observations were reported to the Administrator. The Administrator and DON later entered the resident’s room, donning PPE due to the resident being in COVID-19 isolation, and questioned the resident about any trouble with staff. The resident reported that the CNA had told her she could not turn on her call light because staff were busy, but stated she did not feel abused. The resident’s roommate also reported that the CNA told the resident not to turn on her call light unless she needed something and denied that the resident needed to use the restroom at that time. Another CNA reported that, while standing outside the resident’s closed door, she heard the CNA tell the resident to stop putting her call light on and that she was not going to take her to the bathroom; this CNA later assisted the resident to the bathroom after the call light was turned on again. Despite these multiple staff reports and statements describing yelling, an angry tone, and a statement that the CNA would not toilet the resident, the facility’s initial incident report and follow-up documentation characterized the event primarily as the CNA raising her voice because the resident could not hear through PPE and telling the resident not to turn on the call light unless she needed something. The incident report did not include the allegation that the CNA threatened to withhold services, specifically refusing to toilet the resident. The facility’s policy required immediate reporting of abuse allegations to the Administrator and authorities within two hours and removal of any accused employee from resident contact during investigation, but the CNA continued to work after the initial allegation, and the allegation of refusal to toilet the resident was not accurately reflected in the initial report to the State Agency.
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