Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
A deficiency occurred when the facility failed to prevent verbal abuse between two residents. One resident, who had a history of peer-to-peer altercations, depression, and paranoid schizophrenia, was observed taking an item from the food tray cart without staff permission. Another resident, who was cognitively intact but required substantial assistance with mobility and had vascular dementia, verbally confronted the first resident about this action. The first resident responded with explicit and aggressive verbal comments and approached the other resident with a balled fist, requiring staff intervention to de-escalate the situation and prevent physical contact. The incident was documented by a registered nurse who intervened by stepping between the residents and closing the door to provide a barrier. The facility's records indicate that the resident with a history of altercations was known to be verbally aggressive and difficult to redirect at times. The care plans for both residents identified risks related to abuse and behavioral issues, but the facility did not prevent the verbal altercation from occurring, resulting in a failure to protect residents from verbal abuse as required by the facility's abuse prevention policy.