Failure to Protect Resident from Mental Abuse and Neglect
Penalty
Summary
Facility staff failed to protect a resident from mental and verbal abuse, resulting in psychosocial harm. The resident, who was cognitively intact and had a history of PTSD, depression, and chronic pain, did not receive her prescribed Fentanyl patch as ordered, leading to complaints of pain and withdrawal symptoms. When the resident voiced her concerns and posted signs about her rights and lack of medication, the DON escalated the situation by threatening to have the resident removed from the facility under a temporary detention order (TDO) and involved police and EMS, despite the resident not exhibiting behaviors that warranted such action. The DON also removed the resident's personal signs from her door without consent, further agitating the resident and exacerbating her PTSD symptoms. Multiple staff interviews and documentation confirmed that the resident was not assessed by the DON or other medical personnel prior to the involvement of law enforcement. The resident was not given the opportunity to participate in decisions about her care or to refuse treatment before the escalation. Staff and the Ombudsman reported that the DON's actions were intimidating, retaliatory, and not based on an accurate assessment of the resident's condition. The resident was left feeling scared, embarrassed, and experienced ongoing psychosocial distress, including increased anxiety and night terrors related to the incident. The facility's own investigation, as well as reports from the Ombudsman and Adult Protective Services, substantiated that the resident's rights were violated and that there was neglect in the timely administration of pain medication. The DON's actions, including the threat of a TDO, removal of personal property, and lack of direct assessment, were identified as the primary factors leading to the resident's psychosocial harm and the deficiency cited in the report.