Failure to Timely Report Alleged Verbal Abuse by Resident’s Caregiver
Penalty
Summary
The deficiency involves the facility’s failure to timely report suspected abuse of a resident to the state agency within the required regulatory timeframe. The resident was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder, protein calorie malnutrition, dysphagia, and congestive heart failure, and had a BIMS score indicating moderate cognitive impairment. The resident had an order stating he did not have capacity to make decisions, and his visitor/caregiver was identified as his responsible party and healthcare decision maker. On one date, the resident’s roommate reported to a CNA that the responsible party was physically abusing the resident. Nursing documentation indicated that when the nurse spoke with the resident, he laughed and said they were just fooling around. Another CNA reported that the responsible party was violent, having kicked the wall and bedside drawer after discovering that a pair of scissors had been removed from the drawer. A CNA later described that the caregiver became angry when a razor was missing, talked loudly, became aggressive, and kicked the closet door and trash can while the roommate was present, and stated she was afraid the caregiver was losing control and believed the behavior was potential abuse. The roommate also reported to another CNA that the caregiver was becoming verbally aggressive to the resident. Staff interviews showed that CNAs reported the incident to a licensed nurse on the day it occurred, and CNAs understood that suspected abuse should be reported the same day to the nurse and then to the state, though they were not all familiar with exact timeframes. The licensed nurse who received the reports did not complete or file the abuse report at that time, stating she did not witness the incident, the resident did not indicate he was being abused, and she considered the roommate unreliable, so she only documented the incident in the chart. The administrator later acknowledged that the incident occurred on that earlier date but was not brought to her attention until two days later, at which time the abuse reporting form was completed and sent to the Department, ombudsman, and law enforcement. The facility’s policies required that alleged violations involving abuse be reported immediately, and not later than two hours after the allegation is made, but the report for this incident was not submitted until two days after the initial allegation.
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