Failure to Report and Investigate Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the State Survey Agency (SSA) and to conduct an abuse investigation in accordance with its own policy and regulatory requirements. The facility’s policy on reporting patient abuse, neglect, exploitation, mistreatment, and misappropriation of property required the Administrator or designee to notify the appropriate state agencies, the attending physician, and the patient’s representative of any allegation of abuse, including verbal threats, within two hours of the allegation. The policy also required that an investigation be initiated into the allegation. A resident reported that, after requesting evening medications, she overheard a nurse leaving her room and stating, “I’m not going back in there. I may have to slap someone.” The resident subsequently telephoned her family member to report this statement. The resident’s family member went to the facility, questioned why police had not been notified, and reported that the nurse who initially received his concern did not act and stated he was getting ready to go home. The family member filed a police report that same evening. The resident later filed a formal grievance documenting the nurse’s statement, and the facility categorized the occurrence as a customer service matter, removed the nurse from the resident’s assignment, and planned staff inservices on good customer service. The facility did not report the allegation to the SSA and did not complete an abuse investigation related to the verbal threat. Staff interviews, including with a CNA, the Social Services Director, and the Administrator, confirmed that real or perceived allegations of abuse, including verbal threats, were understood to be reportable and to require immediate reporting and investigation, but this did not occur for this resident’s allegation.
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