Failure to Timely Report Alleged Verbal Abuse to Administration and State Agency
Penalty
Summary
Facility staff failed to immediately report an allegation of verbal abuse involving a resident and a GNA to facility administration and the state survey agency. According to the investigation documentation for a facility-reported incident, a verbal altercation with profane words exchanged occurred between a GNA (Staff #4) and Resident #7 at approximately 6:30 PM, and was witnessed by another GNA (Staff #2). Following this altercation, the involved GNA did not report the incident to administration, and the witnessing GNA also failed to notify facility administration of the verbal altercation. Later that same day, Resident #7 requested to speak to a manager and, during that interaction, reported alleged abuse by the GNA to an LPN Unit Manager (Staff #1) and an LPN Shift Supervisor (Staff #14). The LPN Unit Manager documented that the complaint was taken to the Nursing Home Administrator at approximately 7:15 PM, and the facility’s initial self-report indicated the administrator was notified at approximately 7:30 PM. The facility’s initial self-report was then sent to the State Survey Agency, the Office of Health Care Quality, at 9:20 PM, which was more than two hours after the alleged abuse was witnessed. This delay in reporting was attributed to the failure of the GNA involved in the altercation and the GNA who witnessed the event to promptly notify administration. During a later interview, the DON acknowledged these concerns and stated that the witnessing GNA heard the resident berate the GNA and heard raised voices but did not understand the foul language or what was being said.
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