Failure to Protect Resident from Ongoing Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, specifically in the case involving two residents. One resident, who was cognitively intact but had a history of borderline intellectual functioning, bipolar disorder, and anxiety, repeatedly directed verbal threats, insults, and mocking toward another resident with severe dementia. Multiple staff members, including the DON and NHA, were aware of these incidents, which included threats of physical harm and derogatory remarks made in public areas of the facility. Staff interviews confirmed that the abusive resident regularly made such statements and that these interactions were ongoing. The resident who was the target of the abuse had severe cognitive impairment due to dementia and was unable to fully express his feelings about the incidents. However, his DPOA and staff noted that he would become emotionally upset if spoken to harshly. The care plan for this resident included interventions for managing anxiety and agitation, but there was no evidence that specific measures were implemented to address the ongoing verbal abuse from the other resident. Staff acknowledged that the abusive behavior was a continuous issue and that the resident with dementia was being targeted, but no formal investigation or documentation of interventions was completed. Despite multiple reports and observations of the abusive behavior, including threats and public humiliation, the facility did not take adequate steps to investigate or prevent further incidents. The DON and NHA both confirmed their awareness of the situation but did not initiate an investigation or implement new interventions to protect the resident with dementia. The facility's own abuse policy defined such verbal threats and mocking as mental and verbal abuse, yet the response from staff was insufficient to ensure the resident's safety and dignity.