Failure to Protect Resident from Ongoing Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by another resident and did not take adequate steps to prevent further abuse, including failing to remove the alleged perpetrator from contact with the victim. The affected resident reported ongoing harassment, including being called derogatory names related to race, gender, and sexual orientation, as well as threats of physical harm and death. These incidents were reported to multiple staff members, including the receptionist, social worker, and nursing staff, but the alleged perpetrator remained on the same floor and continued to have access to the victim. The victim expressed feeling unsafe, scared, and unable to sleep due to the ongoing threats and lack of intervention. Interviews and record reviews revealed that the facility staff were aware of the allegations and the ongoing nature of the abuse. Documentation showed that the victim repeatedly reported feeling unsafe and requested that the perpetrator be moved to another floor, but this was not done in a timely manner. Staff interviews indicated inconsistent responses to the allegations, with some staff reporting the incidents to supervisors and others stating that the situation was not considered abuse because both parties were verbally aggressive. Despite the facility's policy requiring immediate separation of residents in abuse allegations and prompt reporting to the state agency, the alleged perpetrator was not removed from the area, and the incident was not reported as required. Both residents involved were cognitively intact and able to move independently in their wheelchairs. The perpetrator had a documented history of verbal aggression toward staff and other residents. Progress notes and staff interviews confirmed that the victim's complaints were documented, but the facility did not provide evidence of a thorough investigation or timely intervention to ensure the victim's safety. The facility's own policies required removal of the alleged abuser and immediate evaluation, but these steps were not followed, resulting in the victim continuing to feel threatened and unsafe.