Failure to Implement Abuse Policy and Timely Psychosocial/Medical Notifications After Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policies by not providing timely interventions and required notifications after an allegation of staff-to-resident verbal abuse. A resident with Alzheimer’s disease, dementia, anxiety, hypertension, dysphagia, and severe cognitive impairment, admitted in late August 2024, was the subject of a substantiated verbal abuse allegation involving a CNA who was observed speaking inappropriately to the resident. The incident was self-reported by the facility, and the resident’s family was notified of the allegation on the day it occurred. However, review of the medical record and facility documentation from the date of the incident through early February 2026 showed no evidence that the physician, social worker, or psychiatric services were notified in a timely manner, despite facility policy requiring such notifications and follow-up. Progress notes lacked documentation of any psychosocial assessment or psychiatric follow-up after the alleged abuse. Interviews with the DON, ADON, and LSW confirmed that social services and psychiatric services were not promptly informed and that psychiatric services were notified only several days later, contrary to facility policy that calls for immediate protection of the resident, examination for injury or psychosocial needs, and provision of emotional support and counseling as needed.
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