Failure to Protect Resident from Ongoing Verbal and Psychological Abuse
Penalty
Summary
The facility failed to protect a resident from repeated verbal and psychological abuse by another resident, in violation of its abuse prevention policy. One resident, who was on hospice care and at high risk for abuse, was subjected to ongoing derogatory name-calling, threats of physical harm, and intimidation by his roommate. The abusive resident, who had a history of criminal behavior and moderate cognitive impairment, repeatedly called the other resident disparaging names, threatened to choke and slap him, and physically kicked his bed. These incidents were corroborated by interviews with the affected resident and a third roommate, who confirmed the ongoing verbal abuse and threats. Despite the ongoing conflict and clear distress experienced by the abused resident, facility staff failed to identify or respond appropriately to the situation. Interviews with staff members, including an LPN and a nurse's aide, revealed that they either did not recall or denied witnessing any inappropriate behavior, arguing, or name-calling between the residents, even though the incidents were reported to have occurred in their presence. The administrator and social services consultant also indicated that they were unaware of any abuse or did not have complete background check results for the abusive resident, whose criminal history screening and fingerprint results were missing or incomplete at the time of admission and during the incidents. The facility's policies required immediate reporting and investigation of abuse allegations, as well as interventions to ensure resident safety. However, these procedures were not followed, and the resident continued to experience fear, anxiety, and emotional distress as a result of the ongoing abuse. Documentation showed that the resident felt unsafe, wrote notes expressing fear for his life, and reported his distress to staff, but no effective action was taken to protect him or address the abusive behavior.