Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as required by its Abuse, Neglect, Exploitation and Misappropriation Prevention Program. During a midday observation, a certified nursing assistant (CNA) was wheeling a resident, who appeared visibly scared and emotionally distressed, through a corridor after a loud altercation. Another resident, standing in a doorway, was observed yelling profanities and a racial slur at the resident in the wheelchair, in the presence of staff and other residents. The resident in the wheelchair audibly expressed fear during the incident. Interviews with staff confirmed that the resident who used abusive language had a history of similar behavior, particularly when frustrated or waiting for food or care. Staff reported that the altercation could potentially have been avoided with increased monitoring, especially during high-risk times such as lunch. The staff member present during the incident intervened verbally to stop the abusive language and attempted to de-escalate the situation, but the incident had already caused emotional distress to the resident targeted by the abuse. A review of the facility's policy confirmed that residents are to be free from all forms of abuse, including verbal and mental abuse. The administrator acknowledged that the language used constituted verbal abuse and should have been addressed according to internal protocols. The incident was witnessed by multiple staff and residents, and the facility was aware of the behavioral history of the resident who committed the abuse.
Plan Of Correction
F-tag: 600 Free from Abuse, Neglect, and Exploitation Immediate corrective action: Resident 23 is no longer in the facility. On 4/30/25, licensed nurses monitored Resident 47 for signs of emotional distress and psychosocial harm from verbal abuse. There were no signs of emotional distress noted. On 5/1/25, Psychiatrist NP came to evaluate Resident 47. There were no negative outcomes as a result of this allegation. Identification of others at risk: The Administrator conducted rounds to identify any resident-to-resident verbal abuse. No other residents were identified with the same deficient practice. Process to prevent recurrence: Licensed nurses will conduct rounds during mealtime to ensure residents' safety. On 05/02/25-05/10/25, the DON/DSD provided in-services to nursing staff (CNA, LVN, RN) to reinforce the policy of Abuse, Neglect, Exploitation or Misappropriation Prevention Program. Monitoring process: The DON will conduct random weekly audits on 4-5 residents for 4 weeks and then randomly for 3 months to ensure that residents are free from verbal abuse. The Administrator findings will be reported to the QAPI committee monthly for further recommendations and resolutions for 3 months or until no negative trends are found. Completion date: 5/20/2025