Failure to Prevent Resident-to-Resident Verbal Abuse and Address Ongoing Disruptive Behavior
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, resulting in the affected resident feeling threatened. Specifically, one resident repeatedly played loud music in his room, which disturbed others. When another resident requested that the music be turned down, the first resident responded with verbal threats and derogatory language. This behavior was ongoing for months, as noted in interviews and progress notes, and was not effectively addressed by staff. The resident responsible for the loud music and verbal abuse was cognitively intact and had a diagnosis of bipolar disorder, but refused interventions such as headphones when offered. Despite multiple complaints and documentation of the disruptive behavior, the facility did not implement or update care plans or interventions to address the ongoing issue. Staff interviews revealed that the only action taken in response to a previous grievance was to move a different resident out of the room, rather than addressing the root cause. The Director of Nursing and other staff acknowledged that the behavior should have been care planned and that interventions were lacking, which contributed to the escalation of the situation and the resulting verbal abuse.