Failure to Prevent and Report Verbal Abuse by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a licensed vocational nurse (LVN). The incident involved a female resident with a history of autistic disorder, fetal alcohol syndrome, epilepsy, and other complex medical and behavioral needs. During a period of behavioral escalation, the resident was subjected to derogatory and confrontational language by LVN B, who made statements such as, "Y'all need to take her ass somewhere," and "Her [family member] needs to come get her!" in the presence of the resident and others. LVN B further engaged in inappropriate behavior by flipping off the resident, making taunting gestures, and inviting the resident to physically confront her. These actions were witnessed by staff, other residents, and a police officer who was present at the time. Multiple staff members, including CNAs and other nurses, observed the incident but failed to immediately report the abuse to the Director of Nursing (DON) or the abuse coordinator as required by facility policy and training. Some staff assumed others would report the incident, while others were unsure of the reporting process or believed the situation was being handled by the police. The DON and Assistant DON were not made aware of the incident until much later, and the abuse coordinator was not notified in a timely manner. The lack of prompt reporting delayed the facility's response and investigation into the abuse. The resident involved was visibly upset during and after the incident, exhibiting behaviors such as yelling, making threats, and attempting to harm herself. The police and staff intervened to de-escalate the situation and prevent further escalation between the resident and LVN B. The incident was corroborated by body camera footage, staff interviews, and the resident's guardian, confirming that the resident was subjected to verbal abuse and inappropriate gestures by LVN B in the presence of others.