Failure to Investigate Alleged Verbal Altercation Between SSD and Resident
Penalty
Summary
The deficiency involves the facility’s failure to investigate an alleged verbal altercation between the Social Services Director (SSD) and a resident, as required by the facility’s abuse investigation and reporting policies and federal regulations. The resident was admitted with diagnoses including morbid obesity and hypertension and had documented capacity to understand and make decisions. An MDS assessment showed the resident was cognitively able to understand and be understood, required varying levels of assistance with ADLs, and was dependent for some transfers and ambulation distances. On the date of the incident, a progress note documented that the SSD asked the resident’s family member to put on a face mask upon entering the resident’s room. The resident asked if there was an outbreak, and the SSD responded that she could not disclose other residents’ information. The note indicated the resident became very upset and started yelling at the SSD for not disclosing the information. As the SSD exited the room, she overheard the resident call her a “bitch,” then returned to the room and asked the resident why she had used that term. There was no documentation in the clinical record that any investigation was initiated or conducted regarding this verbal altercation. In subsequent interviews, the resident reported being afraid of the SSD and described the SSD as trying to fight with her at the beginning of the month when the incident occurred. The resident stated the SSD told her not to worry about the outbreak because she was going to leave anyway and that the SSD should not have entered her room due to multiple prior incidents. The resident further stated that during the altercation the SSD was waving her arms, yelling, asking why she was called a “bitch,” and attempting to re-enter the room, which made the resident feel threatened. The Administrator acknowledged that no investigation was conducted into the incident and stated it had been handled as a grievance instead. Facility policies on abuse prevention and prohibition require investigation of any allegations of abuse, and federal guidance in Appendix PP requires that all alleged violations be thoroughly investigated and reported to the State Survey Agency within five working days, which did not occur in this case.
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