Failure to Investigate Verbal Abuse Allegation and Protect Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse in a timely manner and to implement protective measures for all residents during the investigation. The facility’s Abuse, Prevention and Prohibition Policy required immediate reporting of abuse allegations to the Administrator, a thorough investigation, and barring the alleged perpetrator from resident contact through suspension while the investigation was ongoing. A grievance form dated 12/31/25 documented that a resident reported CNA A was hateful, verbally abusive, refused to warm the resident’s food, and refused to assist the resident to get up. The resident’s admission MDS showed intact cognition, and diagnoses included major depressive disorder, other chronic pain, and CHF. The Social Service Director documented the grievance and reported informing the Administrator that the resident described CNA A as rude, disrespectful, and mean, including refusing to warm food and pull the resident up in bed, and stated the resident did report verbal abuse. The SSD then took the grievance form to the DON as instructed. The Administrator later stated she did not know about the abuse allegation on the grievance form until the survey date and did not recall being informed of what was written on the form. The DON acknowledged she was responsible for investigating abuse allegations but stated she did not think she understood that the word “abuse” was on the grievance form and was unsure if she saw “verbally abusive” on it. Despite the policy requiring immediate suspension of an employee alleged to have committed abuse, CNA A was not suspended and continued to work with the resident and other residents. CNA A reported that the DON had called him/her into the office the prior week and relayed that staff said CNA A threw down the resident’s meal tray, served cold food, told the resident “you get what you get,” did not assist the resident up in bed, and told the resident to butt out of the roommate’s care, which the DON described as borderline abuse. The ADON reported she was unaware of the allegation and stated that staff should notify the Administrator immediately and obtain statements from residents and staff during an abuse investigation. The facility was unable to provide a written investigation or documentation of steps taken to protect all residents during the investigation of this allegation.
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