Failure to Prevent Repetitive Verbal and Mental Abuse Between Roommates
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and mental abuse by another resident. Over a period of time, one resident with moderate cognitive impairment and a history of behavioral disturbances repeatedly yelled at their roommate, telling them to "shut up," "shut your mouth," or to stop talking, both when the roommate was awake and when they were talking in their sleep. These incidents were documented in multiple progress notes and 24-hour report sheets, with staff noting that the yelling was disruptive and occurred on several occasions, often during nighttime hours. The roommate who was subjected to this behavior had severe cognitive impairment and a care plan that instructed staff to approach them in a quiet, calm manner. Despite this, the resident was repeatedly exposed to loud and derogatory language from their roommate. Staff interventions included removing the resident from the room or taking the aggressive resident to a different area until the roommate was asleep, but the verbal abuse continued over several days. Staff and leadership interviews confirmed that telling a resident to "shut up" was considered verbal and mental abuse and that such behavior was not appropriate. Facility policy specified that residents have the right to be free from abuse by anyone, including other residents, and defined verbal and mental abuse as including disparaging language, humiliation, and harassment. Despite staff reminders and attempts to educate the aggressive resident, the facility did not prevent the ongoing verbal abuse, and the affected resident continued to be exposed to repeated incidents of yelling and derogatory remarks from their roommate.