Failure to Protect Resident from Verbal Abuse and Threats by Staff
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, schizoaffective disorder, and bipolar disorder was not protected from mistreatment by facility staff. The resident, who had a BIMS score indicating intact cognition and required assistance for ambulation, became upset after being told they could not leave the facility early in the morning. During the incident, the resident used foul language and slurs toward staff, followed a nursing assistant into another resident's room, and struck the nursing assistant on the arm. Multiple staff members, including a nurse and a supervisor, were involved in attempts to manage the situation. During the escalation, the supervisor responded to the resident's verbal aggression by repeating the same foul language and swearing back at the resident. The supervisor also threatened the resident by stating that they would be given a bath with a pitcher of water if they came any closer. These actions were confirmed through staff interviews and written statements, with the supervisor admitting to using inappropriate language and making the threat. The Director of Nursing and facility manager both acknowledged that the supervisor's response was inappropriate and constituted a threat to the resident. Facility policy prohibits abuse, including verbal and mental abuse, threats, and actions causing mental anguish. Despite this, the supervisor's conduct involved both verbal abuse and a threat of physical action, which failed to ensure the resident was free from mistreatment as required by policy. The facility's internal review did not substantiate the allegation of abuse, citing the resident as the aggressor, but the documented staff actions met the definition of mistreatment under facility policy.