Failure to Investigate and Timely Separate Residents After Verbal Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond appropriately to repeated allegations of resident-to-resident verbal abuse, and to timely separate the alleged perpetrator from the alleged victim. Two cognitively assessed residents shared a room for over two months; one resident had a BIMS score of 12/15 indicating moderate cognitive impairment, and the other had a BIMS score of 15/15 indicating no cognitive impairment. The resident with moderate cognitive impairment reported that her roommate repeatedly yelled, cursed, and used explicit language toward her, stated she was afraid of her roommate, and declined to provide the roommate’s name out of fear of retaliation. She reported that the roommate regularly used offensive language and a confrontational tone and that she was scared of further verbal abuse. Multiple staff members were aware of verbal altercations between the two residents prior to the surveyor’s interview, but the facility did not initiate or document an abuse investigation as required by its Abuse Prevention Policy. The Administrator/Abuse Prevention Coordinator acknowledged that a psychotherapist/LCSW had reported a verbal altercation in which one resident called the other a derogatory name, but the Administrator considered it a grievance rather than potential abuse, did not log it as a grievance, and did not document anything in either resident’s chart. The Social Service Director stated that she directed the psychotherapist/LCSW to report the incident to the Administrator, which occurred, but no internal investigation steps were taken at that time. Additionally, a CNA reported that about a week before the psychotherapist’s report, she and other agency staff heard one resident yelling at the other, observed the alleged victim to be upset, and immediately reported the incident to the Administrator after calming the situation. Despite this earlier report, the Administrator did not interview the CNA or other staff, did not interview the residents regarding the incident, did not initiate an internal investigation, and did not report the allegation to the state survey agency. The facility’s own Abuse Prevention Policy requires that all incidents and allegations involving abuse be documented, investigated, and that residents who allegedly abuse others be immediately evaluated and separated as necessary to ensure safety. These steps were not taken in a timely or documented manner in response to the repeated verbal abuse allegations between these two residents.
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