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 during a card game. One resident became agitated, hit the table, made a fist toward another resident, and yelled profanities and accusatory statements. Staff were unable to immediately redirect the agitated resident, resulting in the other resident feeling fearful and tearful, especially due to a personal history of abuse. The incident was witnessed by staff and substantiated by the facility's investigation. The resident who was the victim of the verbal abuse was cognitively intact and had no prior behavioral issues. She reported feeling afraid of the other resident's outbursts and requested counseling services, but there was no documentation that counseling was provided or that she was notified of any appointments. Her care plan did not include any focus on behavior, mood, or trauma, despite her expressed fears and the incident that occurred. The resident who exhibited the aggressive behavior had a documented history of verbal outbursts toward staff and other residents, including previous incidents of yelling and using profanity. Although there was a behavior contract in place and interventions such as counseling were offered, the care plan was not updated to reflect new orders for psychotropic medication or to include ongoing assessment and monitoring of behaviors. Staff interviews revealed gaps in care planning and documentation, as well as inconsistencies in communication regarding behavioral interventions and counseling services.