F0600

D

Verbal Abuse of Resident During Painful Mechanical Lift Transfer

Phoenix, Arizona Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident’s right to be free from verbal abuse by staff during a transfer. The resident had diagnoses including spinal stenosis, urinary retention, hypertension, fibromyalgia, obesity, muscle weakness, gait and mobility abnormalities, need for assistance with personal care, and low back pain. The care plan identified risk of impaired cognitive function or impaired thought process related to a new environment, with interventions such as using simple, directive sentences, identifying oneself at each interaction, reducing distractions, and providing cues if the resident became agitated. An admission MDS showed the resident was cognitively intact with a BIMS score of 15. Despite these identified needs and interventions, the resident experienced an incident of alleged verbal abuse during a mechanical lift transfer.

During a Hoyer lift transfer from bed to wheelchair, the resident began screaming in pain, calling out about her legs or foot. One CNA involved in the transfer (Staff #5) reported that when the resident continued to scream, she told the resident to calm down and not to scream, stating that the resident had already received muscle relaxant and pain medication. Staff #5 stated she did not intend to diminish the resident and did not recall saying the resident’s feet were not broken. However, the other staff member assisting with the transfer (Staff #3) reported that the resident’s foot hit the Hoyer bar, causing pain and prompting the resident to scream. While the resident was screaming, Staff #3 stated that Staff #5 shouted at the resident to be quiet and said she was behaving as if her foot was broken.

Staff #3 stated she immediately corrected Staff #5, telling her she could not speak to the resident that way. After the transfer, Staff #3 found the resident crying, and the resident stated that Staff #5’s words made her feel abused. Other staff interviewed, including another CNA and an RN, stated that it was not appropriate to tell a resident to be quiet while they were screaming in pain and that such language was disrespectful. The DON and Operations Manager described the facility’s abuse reporting expectations and confirmed that telling a resident to be quiet in this context was inappropriate and unprofessional. The facility’s abuse prevention policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or within hearing distance, and the incident as described met the elements of verbal abuse toward the resident.