Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A deficiency occurred when a cognitively intact resident with multiple medical diagnoses, including coronary artery disease, heart failure, diabetes, and cerebrovascular accident, reported being verbally abused by a Certified Nursing Aide (CNA). The resident, who was independent in daily activities and served as the president of the resident council, stated that the CNA called him an "ass" after he requested that a disruptive roommate be moved. The resident reported this incident to the Director of Nursing (DON), who allegedly attempted to minimize the situation, possibly due to a personal relationship with the CNA. The resident expressed that he felt the comment was abusive and that he was not asked to provide a formal statement regarding the incident. Interviews with the CNA confirmed that she used the term "ass" when addressing the resident and acknowledged that it was disrespectful and a mistake. The DON and Administrator were interviewed, with the Administrator unaware of the incident and the DON describing the resident as being inappropriate with staff. The DON stated she spoke with both parties to resolve the matter. Facility policy clearly prohibits abuse, including verbal abuse defined as the use of disparaging or derogatory language toward residents. The report documents that the facility failed to ensure residents were protected from verbal abuse as required by policy and regulation.
Plan Of Correction
F600 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure residents were safe from abuse, affecting one resident #24. Step 1: Resident #24 was assessed and no negative findings. Resident assessment completed on 6/11/25 by NP. STNA #240 was removed from duty and suspended, personnel file for STNA #240 was reviewed for background check, along with 5 other random staff personnel files, no concerns were identified. Audit completed on 6/6/25. Step 2: To identify other residents that have the potential to be affected, on 6/6/25 the Social Services initiated interviews of those residents able to be interviewed regarding abuse, completing the interviews on 6/6/25 with no negative findings. DON completed skin check on 6-6-25 for non-verbal and cognitively impaired resident with no negative findings. Step 3: To prevent this from recurring, NHA started in-house education with all staff regarding elements of abuse to include verbal abuse. Completed on 6/6/25. New hired staff will be educated on abuse policy during orientation. Step 4: To monitor and maintain ongoing compliance, the NHA/designee will interview 5 residents weekly x4 then monthly x2 to ensure there are no issues with abuse. The NHA/designee will conduct 5 staff interviews weekly x4 then monthly x2 to validate what to do if they witness or hear abuse. The results of the audits will be submitted to the QAPI committee for further review and recommendations. --- F609 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure an allegation of abuse was reported to the state agency, affecting resident #24. Step 1: The incident was reported to ODH and investigated by NHA on 6/10/25. Resident #24 was assessed and no negative findings. Assessment completed on 6/11/25 by NP with no negative finding. Step 2: To identify other residents that have the potential to be affected, on 6/6/25 the Social Services initiated interviews of those residents able to be interviewed regarding abuse, completing the interviews on 6/6/25 with no negative findings. DON completed skin check on 6-6-25 for non-verbal and cognitively impaired resident with no negative findings. Step 3: RDCS educated NHA and DON on reporting of all allegations of abuse on 6-6-25. To prevent this from recurring, NHA started immediate in-house education with all staff.