Failure to Prevent and Intervene in Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to develop and implement interventions to prevent ongoing verbal abuse between two residents sharing a room. One resident, who was dependent on staff for toileting, showering, and transfers due to multiple medical conditions including bilateral osteoarthritis, anemia, and hypertension, reported repeated incidents of verbal abuse and controlling behavior by her roommate. These incidents included the roommate pushing her bed, blocking the door with a wheelchair or walker, making derogatory remarks, and dictating the use of lights and television in the room. The affected resident expressed fear and distress, stating that she had reported these issues to staff but saw no changes. Staff interviews and record reviews confirmed that the roommate frequently blocked the door, used offensive language, and created a hostile environment. A certified nursing assistant (CNA) witnessed the roommate obstructing access to the room and making derogatory comments, and reported these incidents to the director of staff development (DSD). However, there was no evidence that effective interventions were put in place to address or stop the abusive behavior. The social service assistant (SSA) and registered nurse (RN) both documented ongoing conflicts between the residents, with both refusing room changes, but no further follow-up or resolution was documented after grievances were filed. Despite multiple reports and observations of the abusive interactions, facility leadership, including the DSD, regional director, and administrator, were either unaware of the extent of the verbal abuse or did not take further action beyond offering room changes. The facility's own policy required prompt investigation and intervention in cases of alleged abuse, but the lack of follow-up and failure to implement protective measures left the resident at continued risk for verbal abuse.