Failure to Immediately Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy by not immediately investigating and reporting an allegation of verbal abuse involving one cognitively intact resident. The resident, who had multiple medical diagnoses including Type 2 diabetes mellitus with complications, end stage renal disease, peripheral vascular disease, gangrene, acquired absence of foot, hypertension, dependence on renal dialysis, cataracts, obesity, and primary insomnia, had a BIMS score of 15 indicating intact cognition and had a care plan focus for history of abuse or factors increasing susceptibility to abuse. The care plan interventions included reviewing assessment information and emphasizing treatment of causal factors and mental health issues. Despite this, when the resident reported an incident in which a staff member allegedly verbally abused and threatened them, the facility did not treat it as an abuse allegation at the time. The resident reported that one morning in January, during breakfast in the first-floor dining room before going to dialysis, the former dietary manager approached them from behind, got in their face, and accused them of calling her a derogatory name after overhearing the resident’s conversation with a CNA about something seen on television. The resident stated they clarified they were not speaking to the dietary manager, reported the incident to the administrator, wrote a report, and provided a written statement. The resident also stated their family called the state and that the incident was captured on camera. A former dietary aide corroborated that everyone in the dining room witnessed the incident, that the dietary manager approached the resident and backed the resident up while accusing the resident of calling her a derogatory name, and that it was reported to administration and the resident’s family reported it. Another dietary aide stated the former dietary manager had multiple run-ins with the resident and that these were reported to administration. When interviewed, the administrator stated that when the interaction between the resident and the former dietary manager was initially reported, it was handled as a customer service concern rather than an abuse allegation. The administrator described the interaction as a verbal misunderstanding and reported providing verbal counseling to the staff member, but did not provide documentation of an abuse investigation or names of individuals interviewed at that time. The surveyor requested the abuse reportable/investigation multiple times and the facility was unable to produce it, with the assistant DON/HR stating they were trying to get a key to retrieve the reportable while the administrator was unavailable. Only after the surveyor’s request and a subsequent re-interview of the resident did the facility decide to treat the incident as reportable abuse and initiate an abuse investigation, contrary to the facility’s written policy requiring an immediate investigation and timely reporting of all alleged violations of abuse.
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