Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent and protect a resident from verbal abuse by another resident, resulting in a verbal altercation between two residents. On the morning of 06/14/2025, both residents were involved in a heated argument in their shared room, during which they screamed and used foul language toward each other. One resident threatened physical harm, stating, "I am going to f*ck you up," but did not become physically aggressive. Staff intervened and separated the residents, with one being removed from the room. Interviews and record reviews revealed that the altercation was triggered by ongoing disputes, including complaints about housekeeping services and disturbances caused by early morning phone calls. One resident, who has a history of adjustment disorder with anxiety and depression but is cognitively intact, reported feeling stressed and tense during the incident. The other resident, who has impaired cognitive function and diagnoses including dementia and major depressive disorder, reported feeling nervous and needing sleep, and had previously informed a nurse about the disturbances. Behavior notes and care plans for both residents documented their risk for abuse or neglect, with interventions such as providing reassurance and observing the resident when in the company of peers. Despite these interventions, the facility did not prevent the escalation of verbal abuse between the residents, as evidenced by staff and resident interviews and documentation of the incident.