Failure to Protect Resident from Staff Abuse During Behavioral Emergency
Penalty
Summary
A deficiency occurred when a facility failed to protect a resident from verbal, mental, and physical abuse by a staff member, specifically the Human Resource Manager (HR). The incident involved the HR Manager cursing, taunting, threatening, and physically grabbing the resident by the shirt and forcefully placing them into a chair. The HR Manager also aggressively shoved the resident against the wall during a behavioral emergency response. Multiple staff interviews corroborated that the HR Manager used profane language, yelled at the resident, and made threatening statements, including saying he would slam the resident's head through the wall and that he did not care if he lost his job. The HR Manager's actions escalated the situation, and several staff described the behavior as abusive and inappropriate for crisis intervention. The resident involved had a documented history of mental illness, including bipolar disorder, anxiety, impulse control disorder, and other psychiatric diagnoses. The resident was cognitively intact, able to communicate needs, and had a history of behavioral issues such as aggression and spitting when agitated. On the day of the incident, the resident became upset during a smoke break, leading to a behavioral emergency. The HR Manager's response included physical restraint and verbal threats, which were not in accordance with the facility's policies on abuse prevention or nonviolent crisis intervention training. The facility's policy clearly defines abuse to include the willful infliction of injury, intimidation, and the use of threatening or demeaning language, all of which were observed or reported in this incident. Video footage from the facility's cameras, as well as multiple staff interviews, confirmed that the HR Manager used excessive force and inappropriate language during the incident. Staff reported that the HR Manager's demeanor and actions prolonged and escalated the behavioral emergency, rather than de-escalating it as required by training. The administrator did not review the camera footage and relied on the resident's denial of abuse and the HR Manager's denial, despite multiple staff reports and direct observations of abusive behavior. The failure to protect the resident from abuse constituted a violation of the facility's own policies and federal regulations regarding resident rights and safety.