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F0600
D

Resident Subjected to Verbal Abuse by Director of Nursing During Care Conference

Pullman, Washington Survey Completed on 11-10-2025

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 deficiency occurred when a resident, who was cognitively intact and had multiple medical conditions including diabetes, recurrent Clostridium Difficile infection, malnutrition, and adult failure to thrive, was subjected to verbal abuse by the facility's Director of Nursing (DON) during a care conference. The resident required staff assistance with hygiene and transfers due to weakness. During the care conference, the DON made humiliating statements about the resident's bowel incontinence, told the resident they did not belong at the facility, and referred to the resident as a "nasty little man" in front of family members and other staff. Multiple witnesses, including family members, a state worker, and the Social Services Director, confirmed the DON's statements and the resident's distress as a result of the interaction. The incident was reported immediately after the care conference by the resident's family to the facility administrator, but the administrator did not address the concern at that time. The Social Services Director also reported the incident up the chain of command, expecting an investigation to begin, but found the following day that no one had spoken to the resident and the DON was still working in the building. The state worker present at the meeting did not report the incident to the required State Agency, assuming the facility would handle it. Interviews with the resident and family members revealed that the resident felt humiliated, unwanted, and disliked by the DON, and expressed a desire to remain at the facility but to have no further contact with the DON. The DON later admitted to making the derogatory statement and described the resident as acrimonious and belittling, but maintained that the conversation was not one-sided. The administrator acknowledged awareness of the incident but initially did not consider it verbal abuse, only later recognizing it as reportable and requiring investigation.

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