Failure to Protect Resident from Mental Abuse Following Threatening Incident
Penalty
Summary
A resident with moderate cognitive impairment and a history of depression was involved in a verbal altercation with his roommate, who has severe cognitive impairment. During the incident, the roommate alleged that the resident threatened him with a small pocketknife. Nursing staff responded by moving the roommate to another room for safety and conducted a room check, but did not initially find a knife. The resident refused a body check at that time. Later, when the resident's family arrived, the resident produced a small knife from his sock, which was then confiscated. Progress notes indicated that the resident was found agitated, holding a knife, and making alarming statements about having killed before and being willing to do so again. The facility's abuse prevention policy defines threats of harm as verbal abuse and mental abuse, including intimidation and threats of punishment. The facility failed to protect the resident's right to be free from mental abuse, as the threatening behavior was not immediately identified or addressed, resulting in a deficiency.