Failure to Timely Report and Investigate Alleged Verbal and Emotional Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its written abuse policy and to timely report and investigate an allegation of abuse involving a cognitively intact resident with quadriplegia. The resident, who used a slow-moving electric wheelchair and had a BIMS score of 15/15, reported that during her first encounter with a CNA, she asked him to get a food item from the refrigerator. The CNA allegedly responded, “Are you gonna say hi to me if you want something from me?” and repeated this in an angry manner. When the resident replied that she did not have to say hi if she did not want to, the CNA allegedly turned around, yelled that if she did not say hi she would not get anything from him and would have to call her assigned CNA, and then charged toward her with his chest out and aggressive arm movements. The resident stated that this behavior appeared as if the CNA wanted to physically fight her, and she felt scared because her wheelchair moved slowly and she was worried she could not get away fast enough. Following the incident, the resident called for help and reported the event to a CNA and the charge nurse, stating she was scared, did not feel safe, and did not want to be left alone with the CNA involved. A second resident who witnessed the incident confirmed the described events. The charge nurse observed the resident to be very shaken, visibly in distress, and reporting fear. Another CNA reported that she heard the resident screaming her name, found the resident tense and shaking, and was told by the resident that the CNA’s raised voice and body language were intimidating and threatening. This CNA also reported that the resident later felt fatigued, refused to get up, and did not socialize after the incident. Both the charge nurse and the CNA later characterized what happened as abuse. Despite these reports and observations, the incident was not treated and reported as an abuse allegation in accordance with the facility’s abuse policy and regulatory requirements. The policy required that all employees, as mandated reporters, immediately report evidence or suspicion of abuse to the administrator or supervisory nurse, report all abuse to law enforcement by phone immediately, and fax the SOC 341 to the Ombudsman and CDPH within two hours of observation or report. Instead, the charge nurse and CNA did not report the resident’s allegation as abuse to the administrator at the time, and the facility did not initiate a thorough investigation when the incident was first reported. A nurse supervisor later reported the incident to the administrator based only on the CNA’s account and did not include the resident’s statement, and she could not recall what the resident had told her. As a result, the SOC 341 reporting the incident of psychological/mental abuse and verbal aggression was not faxed to CDPH until three days after the alleged incident, contrary to the facility’s policy and required time frames.
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