Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of potential for abuse and neglect was subjected to both verbal and physical abuse by another resident. The incident involved one resident, who is dependent on staff for activities of daily living and has multiple medical diagnoses including spastic quadriplegic cerebral palsy and schizophrenia, being verbally abused with a racial slur and then physically struck on the head by another resident. The care plan for the cognitively impaired resident included interventions such as monitoring whereabouts and behaviors, and staff were instructed to intervene in potential or actual acts of abuse or neglect. The event was witnessed by an LPN, who observed the physically intact resident wheel up to the cognitively impaired resident and strike them on the head with an open palm after the latter was heard yelling a racial slur. The incident occurred in the presence of the physically intact resident’s daughter, who confirmed the verbal abuse. Both residents were assessed after the altercation, with no injuries noted. The facility’s abuse prevention policy affirms the right of residents to be free from abuse by anyone, including other residents, and requires staff to monitor and intervene as necessary. Despite these policies and care plan interventions, the facility failed to prevent the verbal and physical abuse between residents.