Failure to Prevent Verbal Abuse and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse, as evidenced by an incident involving a heated argument between a resident and a kitchen staff member. The resident, who had a history of type two diabetes mellitus, corneal ulcer, muscle weakness, and gastro-esophageal reflux disease, had ongoing issues with receiving double meal portions as ordered. On the day of the incident, the resident requested to speak with the cook regarding his meal, which escalated into a loud argument. Multiple staff members witnessed the cook raising his voice, using discourteous language, and making threatening gestures, including slamming his hands together and telling the resident that if he swung at him, he would be punched. The situation further escalated in the hallway, with the resident following the cook and using derogatory language, and staff needing to physically intervene to separate them. Additionally, the facility failed to prevent and properly document an injury of unknown origin for another resident with severe cognitive deficits and multiple complex medical conditions, including multiple sclerosis, diabetes, and a history of falls. The resident was found to have a significant pressure ulcer with a conjoined skin tear, but there was no documentation regarding when or how the skin tear occurred. Interviews with nursing staff confirmed the lack of documentation and knowledge about the origin of the injury. The DON indicated that the wound may have been related to the resident's use of a Broda chair, but this was based on external hospice documentation rather than facility records. Both deficiencies were identified through interviews, medical record reviews, and examination of facility policies. The facility's own abuse prohibition policy defines verbal abuse as conduct that causes or has the potential to cause humiliation, intimidation, fear, or agitation. In both cases, the facility did not meet its obligation to protect residents from abuse and to ensure proper monitoring and documentation of injuries, as required by policy.