Failure to Protect Resident from Verbal Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with a history of behavioral issues, including yelling and making inappropriate comments, verbally abused his roommate. The abusive resident, who had moderate cognitive impairment and a documented risk for behaviors, repeatedly used foul and threatening language toward his roommate, including a threat to kill him. Staff members, including a CNA and an LPN, attempted to redirect the abusive resident without success. The roommate, who was cognitively intact and had diagnoses including anxiety disorder and major depressive disorder, reported feeling very uncomfortable and requested a room change due to the repeated verbal abuse. The facility's policy prohibits all forms of abuse, including verbal abuse, and requires interventions to protect residents' rights and safety. Despite these policies and the known behavioral risks of the abusive resident, staff were unable to prevent the verbal abuse or effectively intervene to stop the threatening behavior. The situation escalated to the point where the abusive resident admitted to making threats, and staff initiated an involuntary mental health evaluation. The incident was reported to social services, but the initial staff interventions were unsuccessful in protecting the resident from verbal abuse.