F0610

D

Failure to Thoroughly Investigate Resident’s Verbal Abuse Allegation Against DON

Eagle, Colorado Survey Completed on 03-10-2026

Penalty

Fine: $14,015

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse made by a cognitively intact resident against the DON, as required by the facility’s Occurrence Reporting–Vulnerable Adult policy. That policy directed that all suspected or alleged abuse be promptly and thoroughly investigated, including private interviews with the reporter, the alleged victim, the alleged perpetrator, and potential witnesses, as well as documentation of the investigation results. In this case, the resident, who had a history of CVA with left-sided hemiparesis and spastic hemiplegia, depression, ADHD, and other conditions, reported feeling verbally abused and mocked by the DON during an argument related to moving her belongings to a new room. The resident had a BIMS score of 15, was cognitively intact, and had an abuse prevention care plan indicating she was able to report suspected abuse.

On the evening in question, the resident had arranged via email with the NHA for assistance moving to a new room, stating she was not physically able to move her belongings and needed help as an accommodation. The resident reported that no one came to her room at the agreed time, later learning the DON had been waiting in the hallway. When the DON and an RN entered the room, the resident stated that the DON stood between her and the door with hands on her hips, told her staff would move only facility-provided furniture, and insisted the resident move her own personal belongings despite her left-sided paralysis. The resident described feeling cornered and provoked, and reported that the interaction escalated into both parties talking over each other and yelling. She stated that when she requested communication in writing, the DON repeatedly asked if she was going to move her belongings and mocked her request, including questioning whether she could hear, which the resident perceived as demeaning and mocking of her disabilities.

The resident emailed the NHA that evening with a recording of the argument and a written statement, stating she felt mocked and provoked by the DON and describing the DON’s behavior as verbally abusive. The DON also emailed the NHA summarizing the encounter, acknowledging that she repeatedly asked the resident if she was going to move that night and that the conversation became louder as they talked over each other. The NHA later stated she listened to the audio recording, reviewed the written statements from both the resident and the DON, and spoke with the RN who was present, but there was no documentation of these investigative steps. The only written follow-up in the record was a brief statement that the RN confirmed he was present and had nothing to add to the DON’s email; there was no documentation of specific questions asked of him, no documented interview of the resident about the incident, no interviews with other residents regarding their interactions with the DON, and no interviews with other staff to determine if anyone overheard the incident. Additionally, despite the resident explicitly stating she felt verbally abused, the allegation was not reported to the State Agency, and the facility could not produce documentation showing that a thorough investigation consistent with its abuse policy and investigation checklist was completed at the time of the allegation.

The NHA acknowledged that she did not conduct an in-person interview with the resident, stating that the resident’s written statement served as the interview, and that she did not pursue additional interviews with other staff or residents because, after internal review with corporate personnel, they did not substantiate the event as verbal abuse. The DON, who had experience with other abuse investigations and was aware that terms such as “intimidated” or “provoked” should prompt further inquiry, stated she documented her recollection and later listened to the audio with the NHA, but again, no contemporaneous documentation of these steps was available. Review of the resident’s EMR and email correspondence revealed no additional investigation notes or follow-up communication with the resident regarding her abuse claim. As a result, the facility lacked documentation of a prompt, thorough investigation as required by its own policy, including the absence of detailed interviews, witness statements, and analysis of the audio recording, leading to the cited deficiency for failure to thoroughly investigate an allegation of verbal abuse.