Failure to Thoroughly Investigate Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of verbal abuse toward a resident with dementia and impaired cognition. The resident had multiple neurocognitive and psychiatric diagnoses, including unspecified dementia, alcohol-induced dementia, vascular dementia, anxiety, depression, insomnia, encephalopathy, and unspecified psychosis, and had a BIMS score of 09 indicating impaired cognition. The self-reported incident concerned a CNA allegedly making sexually explicit and profane comments to the resident during a smoke break. The facility’s SRI documented that the resident denied physical contact, that assessments showed no physical injury, and that interviews and assessments of other residents and staff revealed no additional concerns, leading the facility to unsubstantiated the abuse allegation. Multiple witness statements and interviews contained inconsistencies and omissions that were not reconciled in the investigation. The roommate’s initial statement, taken by the Administrator, was documented as secondhand information from the resident, and the Administrator later acknowledged being unaware that the cognitively intact roommate had actually been present during the incident and was not asked if he personally witnessed it. In a later interview, the resident reported that the CNA made explicit comments about his genitalia and used profanity toward him during the smoke break, and the roommate corroborated hearing these same inappropriate and profane comments directed at the resident, stating no other staff were present. Despite this, the SRI did not reflect the roommate as a direct eyewitness. Staff witness accounts also conflicted and were not fully reconciled. One LPN provided a handwritten statement describing hearing a loud commotion, seeing the CNA in the smoking doorway passing out cigarettes and “screaming profanities,” and being unsure who the CNA was yelling at; she later emailed a statement with similar content but without mention of residents’ behaviors, and later verified that the typed statement was inaccurate. Another LPN reported observing the CNA cursing and yelling near a common lounge area and that the CNA was sent home for her behavior. A CNA reported seeing the CNA and two residents arguing at the smoking door and noted the CNA had previously treated residents without respect and dignity. The Administrator acknowledged errors and omissions in the SRI, including the CNA’s last name being incorrect, failure to list the CNA as the alleged perpetrator, and inaccurately documenting that the CNA had no prior disciplinary actions, despite a prior final written warning for arguing and using inappropriate or foul language in the presence of a resident, employee, or visitor. These inaccuracies and incomplete witness follow-up demonstrate that the facility did not thoroughly investigate the verbal abuse allegation as required by its abuse policy.
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