Failure to Follow Abuse Policy When Resident Reported Verbal Abuse by Administrator
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse policy and procedure after a resident made an allegation of verbal abuse against the Administrator. The facility’s undated Abuse/Neglect policy stated that the facility would take necessary measures to protect residents from harm during and following an abuse investigation, that allegations of abuse would remain confidential, and that harassment and interfering with an investigation would result in disciplinary action. Despite this, when a resident reported during a PASARR meeting that the Administrator had told him to “shut up, mind your business and don’t say anything” during a prior fall festival, the Administrator was brought into the same meeting and directly confronted the resident about his allegation. The resident involved was an adult male with intact cognitive skills for daily decision-making, with diagnoses including stroke, seizures, and non-Alzheimer’s dementia, and a PASARR-positive status related to intellectual disability. During interview, he reported that at a fall festival he had complained that it was not fair that the festival was not just for residents, and that both the Administrator and Activity Director told him to “shut up, mind your business and don’t say anything,” though he believed the Activity Director was joking and the Administrator was serious. He did not report the allegation until his PASARR meeting, where he stated that the Administrator had spoken to him in this manner. He reported that when the Administrator came into the meeting, she denied saying this, repeatedly put her hand up to stop him from talking, argued with him about what she had said, and remained in the room until just before the other staff left. Staff interviews confirmed that the Administrator, who was also the Abuse Coordinator, was summoned into the PASARR meeting after the resident made the allegation. The MDS nurse stated she brought the Administrator into the meeting because she felt the accused had the right to face their accuser, despite acknowledging that this could cause fear of retaliation and make the resident feel unsafe reporting concerns. The ECC Service Coordinator reported that the Administrator came into the meeting, negated the resident’s claim, stated he was fabricating the allegation due to retaliation, and argued back and forth with him, without leaving the room after the allegation was made. The Administrator herself acknowledged that it was not facility policy to allow the alleged perpetrator to question the resident, and that staff were supposed to contact the DON or corporate staff if she was named as the alleged perpetrator. This sequence of events demonstrated that the facility did not follow its own abuse policy regarding protection of residents, confidentiality of allegations, and prevention of harassment or interference with the investigation process.
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