Failure to Implement Abuse Policy and Timely Report Staff-to-Resident Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy by not ensuring timely reporting of staff-to-resident verbal abuse to the state agency for one resident. The resident was cognitively intact with a BIMS score of 15/15, had a preferred language of Kinyarwanda, required an interpreter to communicate with health care staff, and was independent with ADLs. Her care plan identified communication concerns, a language barrier, and a history of trauma with a goal of no behavior problems, and included interventions such as interpretation services, use of simple and open-ended questions, and calm caregiver interactions. A progress note documented that the resident reported to the Social Services Coordinator, via a translation device, that a CNA had a hostile attitude and used curse words and insults toward her, and that she became very scared and could not sleep the rest of the night. Interviews revealed that the Nursing Home Administrator served as the Abuse Coordinator and expected staff to report any type of abuse at any time. An RN reported witnessing an interaction in which the CNA refused to immediately provide a second cup of water, the resident took a cup anyway, and then grabbed the CNA by the back of the neck; the RN acknowledged she did not report the incident to the Abuse Coordinator in a timely manner and believed she should have. A CNA stated she heard the involved CNA say, “This B**** got me messed up,” did not know to whom it was directed, and walked away without checking on the resident, later telling the RN the next morning that the CNA was “fussing” at the resident. This CNA also reported that she eventually informed the Administrator but could not recall when, despite having been trained on to whom to report such incidents. These actions and inactions by staff led to a delay in reporting the alleged verbal abuse to the state agency, in violation of the facility’s abuse policy.
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