Failure to Report Resident-to-Resident Verbal Abuse Allegations to Administration
Penalty
Summary
The deficiency involves the facility’s failure to report allegations and observations of resident-to-resident verbal abuse to the administrator as required by its Abuse Prevention and Reporting policy. The policy defines verbal abuse as oral or gestured communication such as yelling, mocking, insulting, and ridiculing, and directs staff to consider resident-to-resident altercations as potential abuse that must be investigated and immediately reported to the administrator. Housekeeping and CNA staff reported that two cognitively impaired roommates frequently yelled and cursed at each other, including statements such as “f*** you,” “f****** dummy,” and “you just asked that God d*** it,” over a period of weeks. These staff members acknowledged they would consider this behavior verbal abuse but did not report it to the administrator, instead assuming that because nursing staff or CNAs were aware, no further reporting was needed. The abuse log contained no entry for these incidents, and the administrator confirmed that this situation had not been reported. The deficiency also includes a separate incident involving another pair of roommates, one of whom had moderate cognitive impairment. A housekeeper reported hearing yelling between these two residents and witnessing one resident give the other the middle finger. The housekeeper did not report this as possible abuse, believing that the presence of a CNA in the room was sufficient and expressing uncertainty about whether this behavior constituted abuse due to the residents’ illnesses. The abuse log contained no allegation involving this resident, and the administrator later confirmed that staff should have reported the allegation of one resident giving the other the middle finger. In both situations, staff failed to follow the facility’s policy requiring immediate reporting of suspected abuse to the administrator, resulting in unreported allegations of resident-to-resident verbal abuse for four residents.
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