Failure to Timely Report and Investigate Verbal Abuse Allegation and Remove Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured timely and effective response to an allegation of verbal abuse. A resident representative reported an allegation of verbal abuse involving Resident #1 on 2/14/26 at approximately 8:40 AM to an RN supervisor, providing an audio recording in which staff were heard cursing at the resident while the resident was heard screaming. The RN supervisor notified the DON at approximately 8:50 AM, and the DON notified the Administrator at approximately 9:01 AM. Despite this, the Administrator, who acknowledged awareness of state and federal reporting timeframes and whose job description includes ensuring reportable events are reported within regulatory requirements, did not ensure the allegation was reported to the State Agency within the required timeframes. The facility also failed to implement immediate protective measures and to promptly initiate an investigation after the allegation was reported. Staff schedules and interviews showed that the alleged perpetrator, CNA #2, continued to work in the facility after the allegation was reported on 2/14/26 and remained on duty until 2/16/26 at approximately 11:16 AM, when employment was terminated. Staff confirmed that neither the Administrator nor the DON came to the facility on 2/14/26 and that no staff interviews were conducted that day. The only intervention implemented on 2/14/26 was relocating Resident #1 to another unit at the request of the resident representative. Record review indicated that the facility had an Abuse Policy and Procedure requiring residents to be free from verbal, physical, mental, and sexual abuse and requiring that allegations of abuse be reported and investigated in accordance with regulatory requirements. The facility’s own investigation documented that the allegation was not reported to the State Agency until 2/16/26 and that staff interviews did not begin until 2/16/26. The Administrator confirmed being notified of the allegation on 2/14/26 at approximately 9:00 AM and confirmed awareness of the regulatory timeframes for reporting allegations of abuse. The facility did not have a separate Administration Policy, but the Administrator’s job description required leading operations in accordance with regulations and ensuring reportable events such as alleged abuse are reported to the correct entity within required timeframes.
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