Failure to Prevent Mental Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from mental abuse and did not follow its own Abuse Prohibition Policy and Procedure. One resident, who had diagnoses including schizoaffective disorder, major depressive disorder, and anxiety disorder, reported being subjected to repeated verbal outbursts and threatening behavior from a roommate with a history of psychiatric and mood disorders, including bipolar disorder and PTSD. The roommate exhibited aggressive and verbally abusive behavior, including yelling, using profanity, and, on one occasion, placing a hand on the resident's shoulder and picking up a butter knife in a threatening manner. These actions caused the resident to feel uncomfortable and unsafe. Staff interviews and record reviews revealed that the roommate had a documented history of behavioral issues, including agitation and verbal abuse toward others. The care plan for the roommate included monitoring for aggression and agitation, and the resident was placed on one-to-one supervision to prevent further incidents. However, on the day of the incident involving the butter knife, the assigned CNA stepped away from the room, leaving the roommate unsupervised. This lapse in supervision allowed the altercation to occur, during which the resident was threatened and felt intimidated. The facility's Abuse Prohibition Policy and Procedure explicitly prohibits mental abuse, including threats and conduct that can cause intimidation or fear. Staff acknowledged that the actions of the roommate constituted mental abuse according to the policy and that the lack of supervision contributed to the incident. The failure to maintain required supervision and prevent abusive behavior resulted in the resident experiencing mental abuse and feeling unsafe in their environment.