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F0600
D

Staff-to-Resident Physical and Verbal Abuse in Dining Room

Ozark, Missouri Survey Completed on 06-03-2025

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 certified nurse aide (CNA) physically and verbally abused a resident by grabbing the resident's arm and wrist and cursing at the resident during an incident in the dining room. The resident, who had diagnoses including cancer, nutritional deficiency, dementia with agitation, depression, and Parkinson's disease, was observed to be confused, an elopement risk, and dependent on staff for most activities of daily living. On the day of the incident, the resident was agitated, exit-seeking, and had set off emergency exit door alarms. Staff attempts to redirect the resident were unsuccessful, and the resident struck the CNA in the face during the altercation. Facility video footage and staff interviews confirmed that the CNA repeatedly attempted to physically remove the resident from the dining room by pushing the wheelchair, jerking it, and lifting the front to prevent the resident from stopping movement with their feet. The CNA also pushed the resident's arms abruptly and grabbed at the resident's hands and arms in an attempt to control the resident's movements. During the incident, both the resident and the CNA exchanged profanities, with the CNA responding to the resident's verbal outburst with a curse. The CNA did not seek assistance or attempt to de-escalate the situation by leaving and reapproaching. Interviews with facility leadership and staff acknowledged that the CNA's actions constituted both physical and verbal abuse, as defined by the facility's abuse and neglect policy. The CNA admitted that cursing at or physically redirecting a resident would be considered abuse. Leadership staff, including the ADON and DON, reviewed the incident and agreed that the CNA's handling of the situation was inappropriate and abusive, noting that the resident was permitted to be in the dining room and should not have been forcibly removed.

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