Failure to Implement Abuse Policy and Immediately Report Allegations of Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented the abuse policy requiring immediate protection of residents and prompt reporting of abuse allegations. For one resident with dementia, osteoarthritis, and a mood disorder, a CNA reported that during a transfer to bed, she heard a slap sound followed by the resident crying out that he/she had been slapped, swearing at the CNA involved, and holding his/her face. A nurse who was outside the room also heard a slap and a scream, entered the room, asked the CNAs if the resident had been slapped, and was told no by one of them. The resident then covered his/her face and stated that his/her face had been hit and that he/she could not see. Despite this, the nurse left the room, returned to her medication cart, and allowed the CNAs to continue providing care to the resident before later instructing one CNA to report the incident, resulting in a delay of about 30 minutes from the time of the alleged slap to the report to the Nursing Supervisor. The facility’s abuse policy required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation, and that efforts be made to protect residents from physical and psychosocial harm, including immediate response to protect the alleged victim and removal of the alleged perpetrator. In the case of the resident who alleged being slapped, the nurse did not immediately remove the CNAs from the room or report the allegation to a supervisor at the time she heard the slap and the resident’s statement. Instead, she waited until the CNAs had finished care and left the room before questioning one CNA and directing her to report the incident, contrary to the policy’s requirement for immediate protective action and reporting. A second deficiency involved another resident with traumatic brain injury, morbid obesity, and major depressive disorder, who reported that a hospice aide called him/her a pig, said he/she would be taken to a slaughterhouse, and stated that he/she was a dog who used to live in a cage. A CNA present during these interactions stated that on two or three occasions she witnessed the hospice aide verbally abuse the resident, including calling the resident a “fat pig” and saying the resident would be put in a butcher shop because of having so much meat, then laughing. This CNA did not report any of these incidents until she was interviewed during a facility investigation. Another CNA reported witnessing the hospice aide respond to a racial slur from the resident by calling the resident fat, but initially denied any knowledge of verbal abuse when first questioned and only later disclosed the incident. These staff did not immediately report the alleged verbal abuse as required by the facility’s abuse policy, resulting in a failure to promptly report and address allegations of verbal abuse toward the resident.
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