Failure to Protect Resident from Verbal Abuse by Administrator
Penalty
Summary
A resident with a history of traumatic brain injury, functional quadriplegia, and mood disorders, who was cognitively intact and independent in activities of daily living, was subjected to verbal abuse by the facility's former administrator. The administrator, accompanied by the DON, entered the resident's room to discuss discharge planning. During the conversation, the administrator raised her voice, used derogatory language, and made statements such as telling the resident he was a 'despicable human,' that he 'didn't deserve to be there,' and that he 'needed mental help.' Multiple staff members, including the DON and other nurses, either witnessed or overheard the administrator yelling at the resident, with the incident being audible throughout the hallway and nurse's station. Despite the presence of other staff, including the DON and RN Unit Manager, no one intervened to stop the verbal abuse or remove the administrator from the situation. Witness statements from several staff members confirmed hearing the administrator's raised voice and disparaging remarks, and some staff expressed concern for the resident but did not take action, citing the presence of the DON in the room. The resident was visibly upset and reported feeling abused and discriminated against, later communicating his distress to staff and in an email to the DON. The facility's own investigation, as well as police involvement, confirmed that the administrator's conduct was witnessed by staff and resulted in the resident being emotionally distressed. The facility's abuse policy defines verbal abuse as the use of disparaging or derogatory language, regardless of intent to harm. The administrator was subsequently suspended and terminated, but the deficiency centers on the failure to protect the resident from verbal abuse and the lack of intervention by staff who witnessed the incident.