Failure to Immediately Intervene During Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to immediately intervene when staff heard alleged verbal abuse directed at a resident by her power of attorney (POA). Staff, including a CNA and an RN, overheard loud yelling and profanity coming from the resident's room, with the POA using explicit language and raising her voice. The CNA reported the incident to the nurse, who then notified the Director of Nursing (DON), but neither staff member entered the room or directly intervened to ensure the resident's immediate safety at the time the abuse was occurring. The resident involved had a history of cognitive impairment, including dementia and mood disorders, and was identified as vulnerable to abuse in her care plan. When the DON and Nursing Home Administrator (NHA) entered the room, the POA's behavior de-escalated, but the resident was observed crying. The resident stated she felt safe with her POA and wanted visits to continue, but staff and social services confirmed that this was not the first time the POA had yelled at the resident. Despite the facility's abuse prevention policy requiring immediate protection and intervention for residents at risk, staff did not act promptly to protect the resident during the incident. Staff interviews revealed that while there had been recent education on abuse reporting, the CNA and RN did not physically check on the resident or intervene during the altercation, instead relying on reporting the incident up the chain of command. The care plan and other documentation did not include specific interventions for staff to follow in such situations, and staff were uncertain about what measures were in place to keep the resident safe during and after such incidents.