Failure to Thoroughly Investigate Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse made by a resident against a nurse practitioner. The facility’s abuse investigation policy required that a staff nurse initiate an incident report, notify a supervisor, and that the supervisor and Director of Nursing (DON) determine the need for an investigation and possible reporting to the Department of Health. On 01/05/2026, the Ombudsman notified the facility that Resident #35 alleged that Nurse Practitioner #1 verbally abused them. Resident #35 had diagnoses including Paranoid Personality Disorder, Major Depressive Disorder, and Chronic Obstructive Pulmonary Disease, and a recent MDS documented intact cognition with a need for supervision to moderate assistance for activities of daily living. The facility collected written statements from Nurse Practitioner #1 and the supervising Registered Nurse #4 describing an encounter on 12/26/2025 in which the resident became agitated when awakened, refused to sign for laboratory results, and was verbally abusive toward the nurse practitioner and RN, repeatedly yelling for them to leave the room. Despite the Ombudsman’s report of alleged verbal abuse and the facility’s policy requiring investigation of potential abuse, the facility’s investigation was limited to the two staff statements and did not include an interview or statement from the alleged victim, other residents on the unit, or other staff who might have witnessed the incident or had knowledge of interactions between the nurse practitioner and other residents. During a later interview, the resident stated that the nurse practitioner is “bad” and yells and screams at them. The DON reported that they concluded there was no evidence of abuse and that the resident was actually abusive to the nurse practitioner, noting that the resident tends to confabulate, but there was no documented evidence of a thorough investigation, no documented conclusion of the investigation, and no documented determination of appropriate corrective action if the allegation had been verified. This failure to conduct and document a complete investigation of an alleged verbal abuse incident constituted noncompliance with the requirement to respond appropriately to all alleged violations.
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