Failure to Ensure Resident Dignity and Respect Due to Inadequate Response to Verbal Abuse
Penalty
Summary
A resident with legal blindness, muscle weakness, and cognitive intactness was admitted to the facility and reported being verbally abused by his roommate, who called him derogatory names. The resident stated that staff were aware of the situation and had witnessed the name-calling. Interviews with the roommate confirmed the use of offensive language, and staff interviews corroborated that the behavior had been observed previously. The affected resident also expressed fear of his roommate due to these interactions. Despite multiple reports and observations of inappropriate behavior by the roommate, the care plan for the roommate did not include any interventions for this behavior until several days after the incidents were reported and observed. The facility's policy requires residents to be treated with respect and dignity and to have a safe and comfortable environment, but this was not upheld in this case, as evidenced by the lack of timely intervention and care planning.
Plan Of Correction
F550 – Resident Rights/Exercise of Rights Element #1: Resident #38 and #35 were assessed by the Director of Nursing and/or designee to ensure satisfaction with the room change conducted and psychosocial support provided. Element #2: A facility-wide audit will be completed to identify any additional residents reporting verbal conflicts or roommate issues. All care plans will be updated accordingly. Element #3: The Resident Rights policy was reviewed and updated as necessary by the Administrator. Community staff were re-educated on the Resident Rights policy and the Grievance process. Element #4: The Social Services Director or designee will conduct random audits of 5 resident pairs weekly for 12 weeks to assess interpersonal compatibility and care plan interventions related to dignity and resident rights. Audit findings will be reported monthly to the QAPI Committee for review and corrective follow-up. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025