Failure to Prevent Resident Neglect and Verbal Abuse
Penalty
Summary
The facility failed to protect two residents from neglect and abuse. One resident with spina bifida and quadriplegia, who was totally dependent on staff for care and had moderate cognitive impairment, was left unattended in the courtyard for over an hour. The resident had requested to go outside near shift change, and although staff came outside for smoke breaks, they did not check on the resident. The resident was only discovered and brought back inside during a routine two-hour check. Communication between CNAs was inadequate, as the CNA who took the resident outside claimed to have informed the next shift, but the receiving CNA stated they were not told the resident was outside and only found them during scheduled rounds. Another resident, who was totally dependent on staff for activities of daily living and was cognitively intact, experienced verbal abuse from a CNA. The resident requested assistance with personal hygiene, and the CNA responded by yelling and using foul language. The altercation escalated with both parties exchanging threats and inappropriate language. Witnesses confirmed the CNA's behavior, and the incident was substantiated as verbal abuse. The facility's policy required an abuse-free environment, but staff actions did not prevent or address the abuse and neglect in these cases.