Failure to Report Resident’s Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of verbal abuse to the abuse coordinator for one resident. The resident was recently admitted with multiple diagnoses including chronic kidney disease stage 3, gait and mobility abnormalities, depression, anxiety disorder, cognitive communication deficit, morbid obesity, type II diabetes mellitus, anemia, and chronic peripheral venous insufficiency. A facility assessment showed she was cognitively intact, had no range of motion impairment, used a walker and wheelchair for mobility, and required substantial/maximal assistance with most ADLs. During a visit, the resident’s insurance case manager reported that the resident, who is overweight and sensitive about her weight, stated that a CNA had verbally abused her by calling her “fat” and “big” on several occasions, and that this upset her. In a subsequent interview, the resident stated that on her first day in the facility the CNA told her “You’re so big,” and on days three, four, and five the CNA told her “You’re so fat.” She reported that she told two CNAs and an LPN about these comments but did not recall if she told anyone else. The Administrator stated she had been in communication with the resident since admission and had not received any reports of verbal abuse from the resident or staff. The CNAs and LPN identified by the resident denied that the resident had reported these comments to them. Another CNA later reported that a couple of weeks earlier the resident had told her that the same CNA was calling her “fat,” that the resident felt abused, and that the CNA had not apologized. This CNA acknowledged she did not report the allegation to anyone, despite knowing she should report when someone says they are being abused. The facility’s abuse policy required that all allegations, regardless of source or perceived severity, be immediately reported, thoroughly investigated, and addressed, but this did not occur in this case.
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