F0609

D

Failure to Protect Resident From Verbal Abuse and Timely Report Allegation

Summitville, Indiana Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure staff intervened to protect a resident from verbal abuse by a staff member and to report the allegation of abuse in a timely manner to facility leadership and regulatory agencies. Resident B, who had vascular dementia without behavioral disturbance, anxiety, a prior cerebral infarction, moderate cognitive impairment, and left-sided functional impairment, required extensive assistance with ADLs and had care plans addressing impaired cognition and a history of being verbally abusive with staff. These care plans included maintaining consistent routines and caregivers and encouraging the resident to participate in care to the fullest extent possible. There was no care plan or assignment sheet indication that the resident was restricted from using the showerhead.

On the date of the incident, CNA 1 and QMA 2 were providing a shower to Resident B when CNA 1 moved the resident into the corner of the shower away from the showerhead and refused to allow the resident to use it, stating staff had been told the resident could not have the showerhead. QMA 2 reported she had never been told this. During the shower, CNA 1 threw a washcloth at the resident and told him to wash his “junk,” and engaged in a tug-of-war over the showerhead, ultimately jerking it away from the resident. Resident B corroborated this account, stating that CNA 1 jerked the showerhead away, dumped shampoo on his head instead of into his hand, threw a washcloth at him, and would not allow him to do what he could for himself, unlike other caregivers. The resident reported being upset by the interaction, used profanity to describe the situation, and identified CNA 1 as a staff member who was not nice and would not give him the showerhead.

Despite witnessing this encounter and considering it abusive, QMA 2 did not intervene to stop CNA 1 or remove her from the situation and did not immediately report the suspected abuse to the Administrator or DON as required by facility policy. QMA 2 later stated she did not feel the incident needed to be reported because the resident was not harmed or in distress and that her focus was on avoiding further conflict while continuing care. The incident occurred during the 2:00 p.m. to 10:00 p.m. shift, but was not reported by QMA 2 until the following day, resulting in delayed notification to the Administrator and delayed reporting to regulatory agencies. Additional staff interviews revealed that other CNAs were unaware of any restriction on the resident’s use of the showerhead, that the resident was generally allowed to use it and participate in his own care, and that CNA 1 had previously been “not nice” to the resident, but those concerns had not been reported. Facility leadership confirmed that staff were expected to protect residents first and immediately report suspected or actual abuse, mistreatment, or neglect, and that Resident B was allowed to have the showerhead.