Failure to Protect Resident from Verbal and Mental Abuse by Another Resident
Penalty
Summary
A resident with diagnoses including Bipolar Disorder, Anxiety, and Congestive Heart Failure, who was cognitively intact, was subjected to repeated verbal and mental abuse, as well as physical threats, by another cognitively intact resident. The abusive resident yelled, screamed profanities, and called the victim derogatory names in the presence of another resident, causing the victim to cry, feel embarrassed, and become fearful for her safety. The abusive resident also made sexual comments and advances toward the third resident, further escalating the situation. Multiple staff members and residents witnessed the abusive behavior, including threats of physical harm and an attempt to physically strike the victim, though no physical contact occurred. The victim expressed ongoing fear, altered her behavior to avoid the abuser, and was visibly distressed during interviews. Staff interviews confirmed that the abusive resident's actions were loud, disruptive, and caused significant emotional distress to the victim, who required consolation from both staff and family. Despite these events, the victim's care plan did not include any focus area, goals, or interventions related to her risk of being abused. Nurse progress notes failed to document the altercations, and the psychiatric unit director was not informed that the incidents needed to be reported as abuse. The facility's abuse prevention policy affirms residents' rights to be free from abuse, but the policy was not effectively implemented in this case, as staff did not take adequate steps to protect the victim or monitor the abuser following the initial incident.