Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of possible verbal abuse to the state agency (DHSS) within the required two-hour timeframe, as required by its Abuse, Prevention and Prohibition Policy. The policy stated that any employee or agent made aware of an allegation of abuse or neglect must ensure it is reported to the mandated state agency and law enforcement no later than two hours after the allegation is made. On 12/31/25, the Social Service Director (SSD) documented on a grievance form that a resident reported a CNA was hateful and verbally abusive, became mad when the resident asked for things, and refused to assist the resident to get up. Despite this documentation and the facility’s policy, DHSS records showed the allegation was not reported. The resident involved had been admitted on 12/27/25 with diagnoses including major depressive disorder, other chronic pain, and congestive heart failure, and the admission MDS indicated intact cognitive skills. The resident’s care plan, revised 01/05/26, reflected mood and behavior problems, including refusal to get out of bed and refusal of therapy. On 12/31/25, the SSD spoke with the resident, who stated that every time the CNA came in, the CNA was mean, refused to warm up the resident’s food, and refused to pull the resident up in bed. The SSD documented the resident’s statement of verbal abuse on the grievance form and reported to the Administrator that the resident said the CNA was rude, disrespectful, and mean, and also informed the DON that he had witnessed the CNA being disrespectful and dismissive toward the resident. Multiple staff interviews confirmed that facility staff understood that any allegation of abuse must be reported immediately to a supervisor and to the state within two hours. CNA A and CNA B both stated that allegations of abuse should be reported to the charge nurse and to the state within two hours. The DON and Administrator each stated that staff should report allegations of abuse to them immediately and that the facility should report to the state within two hours. However, the DON stated she did not think she understood that the word “abuse” was on the grievance form, and the Administrator stated she did not know of the allegation of abuse on the grievance form until the survey date and had not checked her email. The SSD stated he emailed the grievance form to the Administrator and believed the resident had stated verbal abuse, but no one reported the allegation to DHSS within the required timeframe, resulting in the deficiency.
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