Failure to Protect Residents from Abuse by Staff and Peers
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in incidents involving both staff-to-resident and resident-to-resident abuse. One resident with moderate cognitive impairment and a history of dementia, psychosis, and anxiety disorder was verbally abused by a registered nurse, who was overheard loudly telling the resident to "shut up" and that she could not disrespect others. Multiple staff members witnessed the incident, and it was confirmed through interviews and documentation that the nurse raised her voice and used inappropriate language toward the resident, contrary to the facility's expectations and policies regarding resident dignity and respect. Another incident involved resident-to-resident abuse, where a cognitively intact resident was subjected to verbal accusations and had coffee thrown on her by a resident with a history of hallucinations, paranoia, and delusions. The aggressor resident, who was known to display verbal behaviors and make false accusations, asked to be moved closer to the other resident and then threw coffee at her. This event was witnessed by a CNA, and interviews confirmed that the coffee was not hot and did not result in physical injury, but the incident was distressing for the resident who was targeted. The facility's documentation and staff interviews revealed that the resident who threw the coffee had ongoing behavioral issues related to her psychiatric diagnoses and medication adjustments. Despite care plans and interventions in place, the facility did not prevent the abusive interactions between residents or the inappropriate staff response, leading to emotional and psychological harm as described by the Director of Nursing. The facility's policy defines abuse to include both staff-to-resident and resident-to-resident altercations, and the events described were found to be in violation of this policy.