Failure to Protect a Cognitively Impaired Resident From Verbal Abuse by a Visitor
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a visitor. The resident was admitted with diagnoses including encounter for palliative care, pneumonia, and UTI, and had severely impaired cognitive skills for daily decision-making per a Quarterly MDS; a BIMS could not be completed, and no behavioral symptoms were documented. On one occasion, a CNA documented that the resident bit a caregiver’s right second finger during care. Later that same day, another progress note documented that a CNA reported the caregiver had put soap in the resident’s mouth because the resident was cursing, and that this was the reason the resident bit the caregiver. The house supervisor was notified of the incident. In interviews, a CNA stated that although veterans may swear frequently, staff and others cannot retaliate, and confirmed that putting soap in a resident’s mouth would constitute abuse. The caregiver, interviewed by phone, stated she had been hired by the resident’s wife as a companion caregiver to assist with cleaning and feeding, recalled a disagreement with the family, and reported having short-term memory loss and not remembering many details. The DON reported that the caregiver told the resident to be nice and stop using vulgar words and warned that people who curse get their mouths washed out with soap; the caregiver had soap on her hands when the resident lunged forward and bit the soap and her fingers. The Administrator, who served as the abuse coordinator, stated that a friend of the family had threatened to wash the resident’s mouth out with soap and confirmed that the resident bit the visitor. Both the DON and Administrator stated that it was not acceptable for visitors to threaten to put soap in residents’ mouths, and the facility’s abuse prevention policy stated that residents have the right to be free from abuse, including verbal and physical abuse.
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