Failure to Report Witnessed Verbal Abuse to Required Agencies
Summary
The facility failed to follow its abuse reporting policy when an allegation of witnessed verbal abuse toward a resident was not reported to the California Department of Public Health (CDPH), the local Ombudsman, or the police department. According to the facility's policies and procedures, all suspected allegations of abuse are required to be reported to these entities. The incident involved a Certified Nurse Assistant (CNA) overhearing another CNA verbally abusing a resident by making derogatory and inappropriate comments about the resident's gender identity and using profane language. The witnessing CNA reported the incident to the charge nurse and the administrator, but the administrator and Director of Nursing (DON) later stated that the allegation was never reported to them, and thus, no report was made to the required agencies. The resident involved had a history of dysarthria following a cerebral infarction, transsexualism (transgender identity), and aphasia, and was her own responsible party. The resident's care plan identified her as female. The failure to report the witnessed verbal abuse as required by policy resulted in a delay in investigation and did not ensure the resident's protection from further harm during the investigation process, as outlined in the facility's procedures.
Penalty
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