Failure to Protect Residents From Ongoing Verbal Abuse and Bullying by a Peer
Penalty
Summary
The facility failed to protect two cognitively intact residents from verbal abuse and bullying by another resident and did not follow its abuse prevention policy. One resident and their mother, who share a room and bathroom with a neighboring resident, reported that the neighboring resident had repeatedly used foul and sexually explicit language toward one of them, including calling them a “b**l sucker” and “d**k sucker,” and made derogatory comments that they “stink.” The two residents stated that this behavior had been occurring for about two months, often when no staff were present, and that the neighboring resident did not want them to use the shared restroom. As a result, they chose to use a bedside commode in their room to avoid ridicule; surveyors observed a bedside commode with urine in it in their room. The two residents reported feeling unsafe, frustrated, angry, stressed, and anxious due to the ongoing bullying and verbal abuse, and one resident expressed fear that reporting the situation might make it worse. Another resident on the unit, who had been in the facility for nearly two years, described the alleged aggressor as someone who becomes “ignorant and disrespectful” when angry, “picks at people,” and “thinks they run this floor,” and reported having heard about conflicts involving the shared bathroom, including accusations that the two residents left the bathroom dirty. This resident also stated that the alleged aggressor knows about other residents’ diagnoses and suggested that this information may have come from staff. Despite these reports and the facility’s own documentation that the alleged aggressor had a history of verbal altercations, verbal aggression toward peers and staff, and manipulative, threatening, and disrespectful behavior, staff interviewed denied awareness of any bullying or abuse between the involved residents and reported no prior incidents or concerns regarding their shared restroom. Progress notes for the alleged aggressor from multiple prior dates documented episodes of verbal aggression and derogatory name-calling, and the resident was care planned for manipulative and aggressive behavior. The facility’s Abuse Prevention Program policy states that residents have the right to be free from abuse, defined as intimidation or punishment resulting in mental anguish, yet the ongoing verbal aggression and intimidation toward the two residents were not identified or addressed by staff prior to the surveyor’s involvement.
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