Failure to Prevent and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse, specifically resident-to-resident abuse, as evidenced by multiple incidents involving one resident verbally abusing others. Three residents with varying medical conditions, including schizophrenia, congestive heart failure, diabetes, cerebral infarction, major depressive disorder, hypertension, COPD, and alcohol-induced psychotic disorder, were subjected to repeated verbal abuse by another resident. These incidents included being called profane and derogatory names, being yelled at, and being chased in a wheelchair. The affected residents were cognitively intact or had moderate cognitive impairment and required varying levels of assistance with activities of daily living. Staff members, including LPNs and CNAs, directly witnessed the abusive behavior but did not report the incidents to facility leadership. Staff interviews revealed a fear of retaliation and a belief that reporting the abuse would not result in any action, as the abusive resident was perceived to have caused staff suspensions or terminations in the past. The Director of Plant Maintenance also observed the abuse but did not report it. Residents confirmed the ongoing verbal abuse and expressed feelings of offense and embarrassment, with one resident stating that nothing was done after reporting the abuse to staff. The facility's records showed no Self-Reported Incidents (SRIs) or investigations related to these allegations during the relevant period. The facility's policy required prevention of all forms of abuse, including resident-to-resident verbal abuse, but this policy was not followed. The Administrator confirmed a lack of awareness of the recent allegations and acknowledged that no SRIs or investigations had been initiated regarding the reported incidents.