Failure to Protect Resident From Verbal Abuse and Missed Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member and to ensure required care was provided. On 1/19/26, a registered nurse (Staff A) entered Resident #1’s room while the Social Worker Aide (SWA) was present and loudly accused the resident of lying and stated she was going to tell her mother to get off his “slot.” The SWA reported that she instructed Staff A to leave the room and believed the interaction was verbal abuse, which she reported to the Social Service Director. Resident #1 reported that Staff A had previously entered his room yelling, telling him to keep her name out of his mouth, which was corroborated by another resident who was visiting at the time. Resident #1 stated he reported the verbal abuse to the Administrator and DON and wrote a grievance regarding missed baths. Multiple staff interviews confirmed that the allegation of verbal abuse was reported up the chain of command, including to the DON and Administrator, both of whom acknowledged that verbal abuse is a form of abuse. Staff A admitted she was angry because she had been informed that Resident #1 was threatening to call 911 and that she went to his room to confront him, calling him a liar. Review of the grievance log showed Resident #1 did not receive a shower or bath on 1/19/26 and 2/2/26, consistent with his complaint that he missed baths and felt he was being retaliated against by Staff A. The facility’s abuse policy requires all employees to respect residents’ rights, treat them with dignity, and immediately report allegations of abuse, neglect, exploitation, or mistreatment to the Administrator and appropriate officials within specified time frames.
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