Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving one resident. The resident had diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, and had intact cognition per a quarterly MDS assessment. The resident’s care plan documented that he had elected to have video monitoring in his room. A Corrective Action Report (CAR) in an LPN’s personnel file, signed on 01/01/26, stated that on 12/01/25 the LPN was observed on video shouting at the resident and using foul or cursing language, and that on 12/22/25 a family member submitted a written concern regarding the LPN’s behavior toward them. The CAR described the LPN’s behavior as disrespectful, abusive, and unprofessional. The Interim DON confirmed that the behavior described in the CAR met criteria for a self-reportable incident due to abusive behavior. The Administrator initially stated she could not determine which resident was involved in the incident, while the Human Resources Director confirmed that the resident with video monitoring was the resident affected by the LPN’s behavior. Review of the resident’s progress notes from 12/01/25 through 12/22/25 showed no documentation of verbal abuse by staff. The Administrator later confirmed that the facility could not provide evidence of any investigation into the incidents involving the resident and the resident’s family member, despite the facility’s abuse policy requiring an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. This lack of investigation was identified as an incidental finding during a complaint survey.
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