Failure to Timely Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state survey agency within 5 working days of the incident. A CNA (CNA A) was alleged to have cursed at and threatened a resident with severe cognitive impairment and PTSD during an overnight shift, and this allegation was not immediately reported by the CNA who learned of it (CNA B), nor was it reported to the state agency within the required timeframe. The report states that this failure to report could place residents at risk for abuse, neglect, exploitation, and/or mistreatment. The resident involved was an older adult with vascular dementia (severe), anxiety, dysphagia, hypertension, hyperlipidemia, cognitive communication deficit, depression, anxiety disorder, PTSD, ataxic gait, lack of coordination, psychotic disorder with delusions, and restlessness and agitation. The resident’s BIMS score was 3/15, indicating severe cognitive impairment, and the care plan documented a history of behavioral episodes including cursing, yelling, hitting other residents, pushing, and attempts to hit staff. The resident required a secure unit and had known sensitivity to noise, yelling, and commotion, which triggered PTSD and aggressive or exit-seeking behaviors. According to interviews and text records, CNA A worked the secure unit on the nights of 12/30 and 12/31 while the facility was short-staffed, caring for approximately 30 residents amid loud fireworks and gunshots in the neighborhood that caused widespread agitation and exit-seeking among residents. CNA B later reported to the DON via text that CNA A had described an encounter in which the resident approached the nurse’s station, raised his hand, and tried to hit CNA A, and that CNA A responded by saying, “Mother fucker you better not hit me or I'm gonna show you.” CNA B acknowledged in interview that she did not immediately report this verbal abuse allegation when she first learned of it from CNA A and stated she should have reported it right away. The facility’s investigation materials and interviews confirm that the allegation of verbal abuse was not reported to the state survey agency within 5 working days of the incident, constituting the cited deficiency. In addition, documentation and interviews show that bruising was later observed on the resident’s right hand and forearm, with RN A identifying the discoloration during morning rounds and documenting it as a change in condition, notifying the MD and responsible party, and obtaining an x-ray that showed osteoporosis but no fracture or dislocation. CNA B’s written statement indicated she had noticed bruising on the resident’s right forearm while providing care on a later shift but assumed it was old and did not report it at that time. While the cause of the bruising could not be determined, the core cited deficiency in the report is the facility’s failure to timely report the verbal abuse allegation involving CNA A and the resident to the state survey agency within the required 5-working-day period.
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