Failure to Prevent Verbal Abuse and Neglect of Resident Care
Penalty
Summary
The facility failed to protect residents from verbal abuse and neglect, as evidenced by multiple incidents involving a nurse (V18). One resident (R7), who was alert and oriented, reported being subjected to loud, verbally aggressive, and combative behavior by V18, including being called by the wrong name, yelled at in a threatening tone, and belittled. Another staff member (V4) corroborated that V18 engaged in unprovoked yelling and used abusive language toward both staff and residents. The Director of Nursing and the administrator confirmed that such behavior is considered verbally abusive and inappropriate. In addition to verbal abuse, the facility did not ensure that residents with tracheostomies received necessary care. Two residents (R2 and R12), both diagnosed with respiratory failure and requiring tracheostomy care, did not receive suctioning as needed during V18's shift. R2 reported difficulty breathing and panic due to lack of suctioning, and R12 was found with low oxygen saturation (88%), which is below the normal range and requires medical attention. Documentation and staff interviews confirmed that tracheostomy care was not provided as required, and R2's call light was not functioning when he attempted to seek help. Furthermore, another resident (R6), who was cognitively intact and diagnosed with diabetes, did not receive her prescribed nightly long-acting insulin because V18 failed to check her blood glucose or administer the medication. R6 did not refuse her medication and attempted to communicate the issue to facility staff. Nursing documentation later confirmed that R6's blood sugar was elevated and insulin was administered by another nurse. The facility's abuse prevention policy prohibits all forms of abuse and neglect, including failure to provide necessary medical care, which was not upheld in these instances.