Failure to Report Resident-to-Resident Verbal Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report a resident-to-resident verbal abuse incident to the state agency as required by regulation and facility policy. One resident had a history of stroke, expressive language disorder, metabolic encephalopathy, anxiety disorder, and vascular dementia, and was documented as cognitively intact on a recent MDS. Another resident had metabolic encephalopathy, muscle weakness, and mild cognitive impairment, and was receiving Divalproex Sodium for aggressive behavior. A progress note documented that the resident with mild cognitive impairment yelled at the cognitively intact resident, used expletive language, and threatened to hit the resident’s head against a table, believing the resident was his sister. The behavior care plan for the resident with mild cognitive impairment, initiated on the same day as the incident, identified potential for verbal aggression toward staff and other residents related to dementia. Interventions included medication administration, analysis and documentation of triggers and de-escalation strategies, assessment of needs, environmental modification, and monitoring and documentation of behaviors and any signs of danger to self or others. Staff, including the Social Services Director and Regional QA Nurse, confirmed that the verbally aggressive resident believed the other resident was his sister and that staff were aware of this history and knew who he was speaking to during the incident. Despite this, the incident was not reported to the state agency as a self-reported incident (SRI). The Regional QA Nurse stated the facility did not view the situation as verbal abuse because the aggressive resident had impaired cognition and the other resident was reportedly unaware that the yelling was directed at her. Review of the facility’s abuse prevention policy showed that verbal abuse is defined as the use of disparaging or derogatory language within hearing distance of residents, regardless of their ability to comprehend or disability, and that all alleged and suspected abuse must be reported immediately to the department of health via online SRI submission. Review of the facility’s self-reported incidents confirmed there were no incidents reported around the date of the documented verbal threat, leading to the finding that the facility failed to report the suspected verbal abuse incident as required.
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