Failure to Protect Resident from Repeated Verbal and Mental Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident (R4) from repeated verbal and mental abuse by another resident (R5) over the course of an entire day, despite staff being aware of the ongoing abuse. R4, who has diagnoses including Bipolar Disorder, Anxiety, and Congestive Heart Failure, was documented as cognitively intact. R5 was also cognitively intact and required supervision for several activities of daily living. On the day in question, R5 repeatedly approached R4, yelling profanities, making threats, and at one point swinging an arm at R4, though not making physical contact. R4 reported feeling scared, changed her activity routine to avoid R5, and experienced significant emotional distress, including crying during interviews and reporting an inability to sleep due to fear of further abuse. Multiple staff members, including the Psychosocial Rehabilitation Director and Assistant, were aware of R5's behavior throughout the day. Staff witnessed R5 using threatening and abusive language towards R4 and acknowledged that R5 should have been placed on closer observation, such as one-to-one monitoring, but this was not done. R4 reported that staff did not intervene or provide protection during the incidents, and only reported the abuse to a Registered Nurse the following morning, whom she trusted to help her. Observations confirmed that there were times when both residents were in common areas without staff present, further exposing R4 to potential abuse. Interviews with staff and a Nurse Practitioner indicated that R5's behavior was out of character and may have indicated a new or acute mental health issue, but no immediate action was taken to remove R5 from contact with R4 or to provide a psychiatric evaluation. The facility's own abuse prevention policy requires that residents who allegedly abuse others be removed from contact with the victim during the investigation, but this was not followed. As a result, R4 was left unprotected and subject to repeated abuse, in violation of facility policy and resident rights.