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F0610
D

Failure to Investigate Allegation of Physical Abuse

Muskego, Wisconsin Survey Completed on 08-06-2025

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

The facility failed to investigate an allegation of physical abuse involving one resident, despite having a policy that requires immediate investigation of all reports or suspicions of abuse, neglect, or exploitation. According to the facility's policy, an investigation should be initiated when any such allegation is reported, including identifying responsible staff, interviewing all involved parties, and thoroughly documenting the process. In this case, a Certified Nursing Assistant (CNA) reported that a Registered Nurse (RN) rolled a resident aggressively onto his affected side and wiped him in a manner that caused visible pain. The CNA documented this incident in a written statement and submitted it to the Director of Nursing. However, there was no evidence that an investigation was initiated for this allegation. The resident involved had significant medical conditions, including hemiplegia and hemiparesis following a stroke, heart failure, diabetes mellitus, and dementia. Despite the CNA's detailed statement and the facility's policy, both the Director of Social Services and the Nursing Home Administrator confirmed that no investigation was conducted, citing the resident's lack of complaint and questioning the emotional tone of the CNA's statement. The surveyor found no documentation or evidence of an investigation into the alleged abuse, which constitutes a failure to respond appropriately to an allegation of abuse as required by facility policy.

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