Failure to Protect Resident from Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, resulting in a substantiated incident of abuse. On the day of the incident, one resident with a history of bipolar disorder, anxiety disorder, and schizoaffective disorder became verbally aggressive and threatened another resident in the dining room. The aggressor raised his fist, attempted to strike the other resident with a chair, and continued to be verbally abusive to staff who intervened. Multiple staff members witnessed the event, and the police were called. The resident who was threatened reported feeling scared for his life and stated he would avoid the dining room due to repeated incidents. Prior to this event, the aggressive resident had a documented history of both verbal and physical aggression toward staff and other residents, including threats, yelling, and attempts to physically harm others. Care plans noted the potential for aggression, but triggers and interventions were not consistently identified or updated in a timely manner. Staff interviews revealed that the aggressive resident's triggers, such as having his dining room space invaded, were not clearly documented in his care plan until after the incident. Staff also reported frequent aggressive outbursts from this resident, with some staff feeling unable to adequately monitor or manage his behaviors due to staffing limitations. The resident who was the victim of the abuse had mild cognitive impairment and required supervision or assistance for most activities of daily living. Documentation indicated that he did not have a history of aggressive behaviors. During the incident, he was subjected to verbal threats and physical intimidation, leading to fear and a change in his dining habits. The facility's failure to identify and address known triggers for the aggressive resident, as well as insufficient monitoring and intervention, directly contributed to the occurrence of resident-to-resident abuse.