Failure to Investigate and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and did not take adequate steps to prevent potential further abuse between two residents. One resident reported ongoing verbal harassment, including racial and sexual slurs, as well as threats of physical harm and death from another resident. Despite multiple reports to various staff members, including the receptionist, social worker, and nursing staff, the alleged perpetrator was not removed from the area or separated from the complainant for an extended period. The complainant continued to encounter the alleged perpetrator daily, which resulted in feelings of fear, emotional distress, and inability to sleep. Interviews and record reviews revealed that staff were aware of the ongoing issues but did not consistently follow the facility's abuse prevention policy. Documentation showed that the complainant repeatedly expressed feeling unsafe and requested that the alleged perpetrator be moved to another floor, but this was not done in a timely manner. Staff interviews indicated confusion about who was responsible for the investigation and reporting during the administrator's medical leave, and there was a lack of clear documentation of a thorough investigation or timely reporting to the state agency. Some staff minimized the severity of the incidents, attributing the interactions to mutual verbal aggression, while others acknowledged the threatening behavior as verbal abuse. Both residents involved were cognitively intact and able to move independently in their wheelchairs. The alleged perpetrator had a documented history of verbal aggression toward staff and other residents. Progress notes and interviews confirmed that threats and derogatory language were used, and that the complainant's concerns were not promptly or adequately addressed. The facility's failure to separate the residents and conduct a thorough investigation resulted in the complainant continuing to feel unsafe and unprotected.