F0609

D

Failure to Recognize and Report Suspected Verbal Abuse Toward Cognitively Impaired Residents

Aviston, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

Facility staff failed to identify and immediately report staff-to-resident verbal abuse involving three residents with cognitive impairments. One resident with malignant neoplasm of the left breast, cerebral infarction, depression, generalized anxiety, unspecified mood disorder, and mild cognitive impairment had a BIMS score of 5, indicating severe cognitive impairment, and adequate hearing. Her care plan identified risk for abuse/neglect with an intervention to report any suspected abuse/neglect to the administrator immediately. The Director of Physical Therapy stated she witnessed an LPN turn to this resident, who was repeatedly asking for her mother, and yell that her mother was dead, after which the resident became very upset and cried. The Director of Physical Therapy described the LPN’s behavior as verbally and mentally abusive but did not report this incident to the administrator or DON, despite facility policy requiring immediate internal reporting of suspected abuse.

Another resident with Alzheimer’s disease, unspecified dementia, major depressive disorder, and insomnia also had a BIMS score of 5 and adequate hearing, and a care plan identifying risk for abuse/neglect with instructions to promptly address complaints and report suspected abuse to the administrator. A RN reported that a newer LPN was verbally mean to most residents and had yelled at this resident, who liked to sleep in, from the hallway, telling her she needed to get out of bed and that she was getting up, which the RN considered verbal and mental abuse. The RN admitted she did not report this behavior because she felt it would “put a target on your back.” Another LPN reported that on a weekend the same LPN yelled very loudly and rudely at this resident while she sat near the nurse’s station, upsetting her, and that on another occasion the resident cried when she was not allowed to call her son. This LPN also did not report these incidents to the administrator or DON.

A third resident with cerebral palsy, paraplegia, vascular dementia, bipolar disorder, major depressive disorder, anxiety disorder, and unspecified intellectual disabilities had a BIMS score of 11, indicating moderately impaired cognition, and adequate hearing. Her care plan did not include a focus area for abuse. She reported that an LPN told her in a loud voice that she had to get up and take a shower, despite her usual practice of receiving bed baths due to back and spine problems and fear of mechanical lifts after a prior fall from a lift sling at another facility. She stated that staff, at the LPN’s direction, got her up with a mechanical lift for a shower, during which she cried and was very upset. Another LPN corroborated that the LPN insisted staff get this resident up for a “real shower” despite her refusals and fear of the lift, and that the resident was crying and screaming, but this was never reported to the administrator or DON. A CNA confirmed she gave the resident a shower at the LPN’s direction despite the resident’s refusal to get out of bed, and another CNA reported hearing the resident yelling and screaming during the shower, noting it was the first time she had seen the resident get up for a shower. These events, along with staff statements that they did not report the LPN’s conduct, demonstrate a failure to recognize, internally report, and escalate suspected verbal abuse as required by the facility’s Abuse Prevention Program policy.

The facility’s Abuse Prevention Program policy requires employees to immediately report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect to the administrator, with specified time frames for reporting based on seriousness, and directs that employees immediately inform the administrator of all such reports so that an investigation can be initiated. Multiple staff, including the Director of Physical Therapy, a RN, and an LPN, acknowledged witnessing or being aware of verbally abusive or coercive interactions by the LPN toward these residents but did not report these concerns to the administrator or DON at the time they occurred. The failure of these staff members to follow the internal reporting requirements resulted in suspected verbal and mental abuse not being promptly identified or reported to facility leadership as required by policy.