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F0600
D

Mental Abuse of Resident by Agency CNAs via Social Media Video

Charleston, Illinois Survey Completed on 04-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with diagnoses including Alzheimer's disease, cognitive communication deficit, Parkinson's disease, and generalized anxiety disorder, who was severely cognitively impaired and dependent on staff for mobility, was subjected to mental abuse by two agency CNAs. The incident involved the CNAs repeatedly locking the resident's wheelchair brakes while taunting him to move faster, despite his inability to do so. The CNAs took turns locking and unlocking the wheelchair, causing visible distress, anxiety, and confusion in the resident, who was unable to understand or respond appropriately due to his cognitive and physical limitations. The abuse was recorded on video and posted to social media by one of the CNAs, with the other CNA re-posting it. The video showed the resident in a corner, facing a blank wall, being taunted and prevented from moving. Observers of the video, including an LPN and another CNA, described the resident as appearing very upset, anxious, and in distress throughout the duration of the video, which lasted less than a minute. The actions of the CNAs were described as antagonizing and intended to cause mental harm, with the resident unable to escape or defend himself due to his condition and the physical restraint imposed by the staff. The facility's abuse prevention policy explicitly prohibits all forms of abuse, including mental abuse facilitated by technology such as unauthorized video recordings and social media posts. The policy defines mental abuse to include humiliation, harassment, and the use of recordings in a manner that demeans or humiliates residents. The actions of the CNAs, as documented in the video and described by staff, were in direct violation of this policy, resulting in the resident being subjected to mental anguish and humiliation.

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