Failure to Protect Residents From Verbal and Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively intact residents from verbal and sexual abuse by another resident, identified as R4. R3, with schizophrenia, generalized anxiety disorder, neuralgia and neuritis, and a BIMS score of 14, reported that R4 followed him in the hallway, asked to use his laptop and headphones, and later entered his room around 2:00 a.m., calling him a “b****” and telling him to perform a sexual act when R3 told him to leave. R3 stated that R4 told him he could come into his room if he wanted to and that, after being sent to the hospital and returning, R4 again came into his room around 2:00 a.m. R4’s nursing progress notes documented agitation, aggressive behavior, and that he went to another floor to harass a female resident. R14, with major depressive disorder, schizoaffective disorder, essential hypertension, hidradenitis suppurativa, and a BIMS score of 15, reported that R4, newly admitted, came onto her unit where he did not belong and made sexual remarks about his penis size and wanting someone to perform oral sex at the nurses’ station. She stated that when staff told R4 he could not take snacks from that unit, he became aggressive, called them “bitches,” made threats to kill them, and repeatedly left and returned to the unit. R14 further reported that during a meal in the dining room, R4 got in her face, motioned toward her with a balled fist, called her a “fat bitch,” threatened to shove a cane into her buttocks, and stated proudly that he was a pedophile when she told him he was acting like one. She also reported that he continued roaming her floor after bedtime and attempted to follow her to see which room she was going to until a nurse intervened. Staff interviews corroborated that R4 repeatedly came to the second floor, where female residents including R3 and R14 were located, and made inappropriate and threatening remarks. An agency RN (V13) stated that R4 was pacing, unable to be redirected, and was reported to be harassing female residents on another floor, becoming loud and aggressive. Another agency RN (V6) reported that R4 came to the second floor several times, made inappropriate remarks to R3 and R14, refused multiple redirection attempts to return to his own unit, and then began yelling, calling them “bitches,” and threatening to punch them in the face before eventually returning to his floor. The DON acknowledged that residents have a right not to be harassed or verbally assaulted and that all residents should feel safe. Facility policy states that residents have the right to be free from abuse, including verbal and sexual abuse, and that administration is responsible for protecting residents from abuse by anyone, including other residents.
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