F0600

J

RN Kicks Cognitively Impaired Resident During Attempted Floor Transfer

Mount Sterling, Illinois Survey Completed on 01-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to de-escalate a cognitively impaired resident’s behaviors and to protect the resident from staff-to-resident physical abuse. The facility had an Abuse Policy and Employee Handbook that prohibited abuse and workplace violence, including physical abuse such as kicking, and required staff to report any allegation or witnessed abuse immediately. Despite these policies, a registered nurse (V4) engaged in physical abuse toward a resident (R1) with known behavioral issues, resulting in psychosocial and physical harm.

R1 was a severely cognitively impaired resident with diagnoses including profound intellectual disabilities, depression, traumatic brain injury, and vascular dementia with agitation. R1’s care plan documented a history of trauma, childlike behaviors, and a pattern of placing himself on the floor and stating he had fallen in attempts to get his mother to visit. The care plan also indicated that R1 was generally independent with transfers but at times required one-person physical assistance, and that staff were to provide reassurance to help R1 feel safe and secure. On the date of the incident, R1 was on a floor mat, a behavior described as not abnormal for him, and was noted to be agitated and combative when staff attempted to move him using a mechanical lift sling.

According to progress notes, written statements, and staff interviews, V4 obtained a mechanical lift sling and directed CNAs (V21 and V23) to assist in placing the sling under R1 to transfer him from the floor, despite R1 yelling “no” and becoming combative. Witness statements from V21 and V23 describe R1 pushing and pinching V4 while staff attempted to position the sling, and both CNAs reported that V4 responded by kicking R1 three times above the left hip/left buttock with the side of her shoe. R1 cried, had visible tears, yelled that he had been kicked, and demanded that V4 leave his room. V21 refused to continue assisting with the sling, told V4 that no title gave her the right to kick a resident, and identified the behavior as abuse. V23 similarly characterized the kicking as physical abuse and noted that V4’s stern communication appeared to further agitate R1. In a subsequent interview, V4 acknowledged bringing her knee up and hitting R1 in the left hip after being pinched, and the administrator later confirmed that kicking a resident three times under these circumstances constituted physical abuse.

The incident resulted in R1 experiencing fear, mental anguish, and pain, and was determined by surveyors to constitute an Immediate Jeopardy situation beginning on the date of the kicking incident. The facility’s own investigation and administrative summary documented that a CNA witnessed the RN make contact with R1’s left upper leg with her foot after R1 either pinched or hit her while staff were attempting to de-escalate his behaviors and assist with a transfer. R1’s power of attorney was informed of the event and described being stressed about the situation, stating that staff, including V4, should know how to deal with difficult residents and characterizing the kicking as physical abuse that would have hurt R1’s feelings and led him to cry or lash out. The combination of R1’s known behavioral and trauma history, his resistance to the sling transfer, and V4’s physical response to his behaviors formed the basis of the cited deficiency for failure to prevent abuse and to appropriately de-escalate a resident’s behaviors.

The Immediate Jeopardy was later determined to have been removed, but the facility remained out of compliance at a lower severity level pending evaluation of the implementation and effectiveness of its removal plan and Quality Assurance monitoring.

Removal Plan

• V4 was suspended immediately and then terminated from employment.
• The Director of Nursing completed skin assessments on R1 post incident with no signs of injury related to the incident.
• The Social Service Director completed trauma risk assessments on R1 to ensure R1 had no concerns post incident.
• V1 and the Corporate Nurse Consultant completed all staff in-servicing regarding abuse and de-escalation training including contracted staff.
• All staff were in-serviced prior to their shift on stress management, caregiver strain, and burnout.
• The QAA team completed a full QAA identification and QAPI plan of correction for R1's incident.
• R1's Care Plan was updated with interventions to instruct staff on what to do if R1 chooses to sit on the floor.