Failure to Protect Resident from Repeated Verbal Abuse by POA
Penalty
Summary
A resident with moderate cognitive impairment and a history of childhood abuse was subjected to repeated verbal abuse by her activated Power of Attorney (POA) while at the facility. The POA was reported to have yelled, used profanity, and displayed aggressive behavior toward the resident on multiple occasions, including incidents where staff overheard loud, profane language and observed the resident crying. Despite these events, the facility did not implement or document specific interventions to prevent further verbal abuse or to ensure the resident's safety during visits from the POA. The resident's care plan and Kardex did not include any interventions or increased monitoring related to the POA, even though the facility's policies defined verbal abuse and allowed for visitation restrictions in cases of emotionally harmful behavior. Staff interviews revealed a lack of awareness regarding any interventions or special precautions for the resident when the POA was present. While some staff were aware of a memo at the nurse's station instructing them to report any yelling by the POA, this information was not consistently communicated to all staff, including new or agency staff, and was not reflected in the resident's care documentation. Multiple staff members, including CNAs, nurses, and support staff, acknowledged hearing or being aware of the POA's verbally abusive behavior toward the resident. However, there was inconsistency in staff responses, with some not intervening or being unclear about the appropriate actions to take. The facility leadership chose not to document interventions in the care plan or Kardex, citing concerns about the POA's access to these documents. As a result, the facility failed to ensure that effective measures were in place to protect the resident from ongoing verbal abuse by the POA.