Failure to Thoroughly Investigate Resident-to-Resident Verbal Abuse and Remove Alleged Perpetrator from Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into two separate resident-to-resident verbal abuse allegations and to remove an alleged perpetrator from a shared dining room after witnessed verbal abuse. In the first incident, a state report dated 01/16/26 documents that an allegation of verbal abuse occurred between residents identified as R16 and R17 in the dining room. The facility’s investigation included staff witness statements but did not include interviews with other residents who were present in the dining room. Subsequent interviews revealed that another resident (R7) overheard R16 yelling “pretty bad words” at R17, causing R17 to leave crying, and another resident (R14), who dined at the same table as R16, recalled R16 “cussing up a blue streak” at R17 and described the behavior as uncalled for. R16 later admitted to yelling harsh curse words at R17 because he believed R17 was laughing at him, and R18, who was present, confirmed that R16 was agitated, yelled curse words, and that R17 left the dining room upset and crying. Despite this, R16 and R18 remained in the dining room to finish their meal, and a dietary assistant (V33) stated she witnessed the verbal abuse while other unidentified residents were present. In the second incident, a state report dated 12/12/25 documents an allegation of verbal abuse between residents R3 and R4 in a hallway near the nursing desk. A CNA (V50) reported that while charting at the nursing desk, she heard R3 cursing at R4 and telling him she hoped he would choke on his water and die; when R4 questioned what was said, R3 repeated the statement. V50 told R3 the behavior was not acceptable and removed her from the hall, then reported the incident to the Assistant DON (V51) and the Administrator/Abuse Prevention Coordinator (V1). R3 later did not recall the incident, and R4 stated he did not recall the exact words but knew R3 was not nice and cussed at him. The investigation documentation for this incident did not include additional resident or staff interviews beyond these statements. During review of the hard-copy investigations, the Administrator/Abuse Prevention Coordinator (V1) acknowledged that both investigations lacked witness statements from other residents, which are part of a thorough investigation, and also acknowledged she had misunderstood R16’s post-incident location and that R16 should not have remained in the dining room after shouting profanities at R17.
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