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F0600
G

Failure to Protect Resident from Physical Abuse by CNAs

Eureka, Illinois Survey Completed on 11-04-2025

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 cognitively intact resident with multiple medical conditions, including acute pyelonephritis, cerebral infarction, rheumatoid arthritis, osteoporosis, and mobility deficits, was subjected to physical abuse by two certified nursing assistants (CNAs) during care. After returning from physical therapy, the resident was wheeled to her room by the CNAs, who became verbally forceful and demanding when she was unable to transfer herself from her wheelchair to a recliner due to her physical limitations. Despite the resident's attempts to explain her inability to comply, the CNAs yelled at her, accused her of being uncooperative, and proceeded to physically grab her under her arms, squeeze her, and forcefully throw her into the recliner. The incident resulted in the resident sustaining multiple bruises on both upper arms, with the bruising described as being in the shape of finger pads and purplish in color. The injuries were documented in the resident's medical record and confirmed during a skin check, which noted several bruises of varying sizes on the resident's arms and axillae. The resident reported pain and distress during the incident and expressed a desire not to have the involved CNAs provide her care in the future. The abuse was reported by another CNA to the Director of Nursing, who then notified the local police. The police officer interviewed the resident, who recounted the details of the incident and allowed photographs of her injuries to be taken. The resident declined to press criminal charges but requested that the CNAs be disciplined by the facility. The facility's policy on abuse, neglect, and exploitation defines such actions as willful infliction of injury and includes staff-to-resident abuse, which was substantiated by the findings in this case.

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