Failure to Protect Resident From Verbal Abuse During Water Pass
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by staff. The resident was cognitively intact, scored 15/15 on the BIMS, spoke Kinyarwanda, and required an interpreter to communicate with health care staff. Her care plan identified communication concerns, a language barrier, and a history of trauma/PTSD, with interventions including use of interpretation services, simple questions, open-ended questions, and calm communication to promote positive interactions and prevent behavior problems. Despite these identified needs and interventions, staff interactions during the incident did not reflect the care-planned approaches. According to a progress note, the resident reported to the Social Services Coordinator, using a translation device, that a CNA had a hostile attitude and used curse words and insults toward her, leaving her very scared and unable to sleep the rest of the night. The Social Services Coordinator recalled the incident as centering around a CNA pulling something away from the resident. An RN who was present on the night of the incident stated that the CNA was passing water, the resident requested two cups, and when the CNA refused and said she would return later with another cup, the resident grabbed a cup and then grabbed the CNA by the back of the neck. The RN reported that the CNA told the resident not to touch her and that no other staff were around at that time, and also stated that the Administrator did not interview her about the incident. Another CNA reported overhearing the involved CNA say, “This Bitch got me messed up,” while wearing earbuds and talking, and believed the CNA was talking about the resident, but did not intervene or check on the resident because she felt the CNA had been a bully. The CNA accused of verbal abuse stated she refused to give the resident a second cup of water immediately, that the resident followed her speaking in Kinyarwanda, snatched a cup of water, and grabbed her shirt, and that she told the resident not to grab her but denied calling the resident any names. The resident, interviewed with a translator, stated that when she requested two cups of water, the CNA refused without explanation, pushed at her when she reached for a cup, and said, “Fuck, Fuck Bitch,” which made her feel very bad. These accounts demonstrate that the resident was subjected to hostile and profane language by staff, contrary to her right to be free from verbal abuse and to the care-planned interventions for communication and behavior related to her trauma history and language barrier.
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