Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by incidents involving two residents. In the first case, a resident with a diagnosis of malignant neoplasm of the brain and chronic pain reported repeated upsetting interactions with a CNA. The resident stated that the CNA would enter her room multiple times, engage in arguments, and make statements such as questioning if the resident's brain was working. Witness statements from staff corroborated that the resident became visibly upset and was shaking after these encounters. The CNA admitted to explaining medication schedules to the resident but denied any intent to antagonize her, while other staff intervened to remove the CNA from the situation when the resident became distressed. In the second case, a resident with autosomal dominant limb girdle muscle dystrophy and intact cognition was involved in a verbal altercation with the Dietary Coordinator (DC). The DC was reported to have yelled and used profanity towards the resident after the resident insulted her regarding a missing lunch tray. Multiple staff witnesses confirmed hearing the DC use profane language both in the resident's room and in common areas, with the DC admitting to telling the resident to "shut up" after reaching her "boiling point." The resident later confirmed being very angry at being told to "shut the f*ck up" by a staff member, although he stated he was "over it" at the time of interview. Facility policy review indicated that residents are to be treated with respect, kindness, and dignity, and that abuse, including verbal abuse, is not tolerated. Despite investigations determining that there was no willful intent to harm in either case, the actions and statements of staff members resulted in residents experiencing distress and being subjected to unprofessional conduct. The deficiency was substantiated based on direct observations, resident and staff interviews, and review of facility documentation.