Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident. One resident, who is legally blind, has dementia, anxiety, and requires maximum assistance with daily activities, was subjected to repeated verbal threats and aggressive comments from his roommate, who is severely cognitively impaired. The roommate had a documented history of verbal and physical aggression, including a psychiatric evaluation following threats to kill his roommate and staff. The roommate stated he would act on his threats due to his military training and continued to make threatening and aggressive statements toward both the resident and staff, as witnessed by a CNA and documented in the facility's report to the state agency. Staff interviews and record reviews revealed that the verbally aggressive resident had previously been sent to a psychiatric facility for homicidal ideations and had a pattern of outbursts toward other residents and staff. Despite these known behaviors, the resident was returned to the facility after medication changes, and there were no further incidents reported after his return. The facility's abuse prevention policy defines verbal abuse as the use of threatening or frightening language, which was consistent with the behaviors observed and documented in this case.