Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with multiple medical and cognitive conditions, including cerebral infarction, legal blindness, chronic pain syndrome, and moderate cognitive impairment, was not protected from verbal abuse by a staff member. The resident had a documented history of communication impairment and behavioral challenges, including agitation, use of profane language, and making false accusations. Despite these challenges, the care plans in place directed staff to anticipate and meet the resident's needs, maintain effective communication, and support the resident's comfort and dignity. On several occasions, staff and witnesses reported that a CNA engaged in loud arguments and used profanity toward the resident, including telling the resident to "shut the fuck up." Multiple interviews with staff, a student CNA, and the resident confirmed that such interactions were not isolated incidents but rather frequent occurrences. The resident consistently reported that CNAs yelled and used profanity, and a student CNA and other staff corroborated hearing the CNA argue and use inappropriate language. Facility documentation and interviews revealed that staff often did not report these incidents, considering them unprofessional but not necessarily abuse, and some staff justified the loud tone due to the resident's hearing deficit. The facility's own policies strictly prohibited demeaning, intimidating, or harassing behavior, including swearing and shouting, and required staff to treat residents with kindness, respect, and dignity. Despite these policies, the CNA in question had a documented history of unprofessional conduct, including previous incidents of arguing with residents and staff. The facility's investigation into the verbal abuse allegations was ultimately inconclusive, but firsthand accounts and interviews indicated that the resident was subjected to repeated verbal abuse, and staff failed to consistently recognize, report, or intervene in these situations as required by policy.