Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse and initiate an investigation in accordance with its abuse reporting policy and federal requirements. Resident #23, admitted on 02/02/26 with diagnoses including bipolar disorder (current episode manic without psychotic features, moderate), anxiety disorder, hypothyroidism, mixed hyperlipidemia, major depressive disorder (single episode, severe, without psychotic features), and hypertension, was documented as cognitively intact on the admission MDS. The MDS also showed the resident required supervision for toileting, bathing, dressing, and transfers, setup assistance for oral and personal hygiene, and was independent with eating and bed mobility. On 02/16/26, a provider visit note signed by Former Nurse Practitioner #175 documented that Resident #23 reported an incident in which a staff member, identified as LPN #94, became angry, yelled, and used profanity toward the resident. Review of the facility’s electronic Self-Reported Incidents (SRI) system from 02/16/26 to 03/11/26 showed no alleged incidents involving this resident had been entered. During an interview on 03/11/26, the Administrator stated she had not been informed of any abuse allegation involving LPN #94 and Resident #23 and indicated she would have reported and investigated the allegation if she had been made aware. Review of the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised 04/2021, showed the facility was required to investigate and report any allegations within federally required timeframes; this did not occur for the allegation involving Resident #23.
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