Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state agency as required by policy. A resident with intact cognition, admitted with diagnoses including cervical spinal stenosis, osteomyelitis, type II diabetes mellitus, and muscle weakness, was care planned to require assistance of two staff for bed mobility and mechanical lift transfers. On the date in question, an RN requested that a CNA transfer the resident to bed so wound dressings could be changed. Later, the CNA reported to the RN that the resident refused to get into bed and that the resident had asked for help to clean off her bed so she could be transferred. The CNA also reported telling the resident, "you made the mess on the bed, you can clean it up," and did not assist the resident with cleaning the bed or transferring her, resulting in the ordered dressing changes not being completed that day. The RN considered the CNA’s statement and failure to assist as inappropriate and reported this information by text message to the ADON that evening. The ADON received the RN’s text describing the CNA’s refusal to help and the statement made to the resident but did not consider it verbal abuse and took no further action at that time. The ADON did not report the allegation to the DON and did not initiate an investigation until two days later, at which time the DON was informed. Interviews confirmed that the resident did not recall the specific alleged statement but did recall that the CNA said she would return after answering another call light and did not come back, and that the dressing change was not completed as ordered. The facility’s abuse, neglect, and exploitation policy required that alleged violations be reported immediately, but not later than two hours if involving abuse or serious bodily injury, and not later than 24 hours otherwise, to the Administrator, state agency, adult protective services, and other required agencies. The failure of the ADON to promptly report the allegation and initiate an investigation, and the lack of timely reporting to the state agency, constituted non-compliance with the facility’s abuse reporting policy.
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