F0600

J

Verbal Abuse of Resident by Dietary Staff During Snack Service

Edwardsville, Kansas Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from verbal abuse by a staff member. The resident had diagnoses including paranoid schizophrenia, anxiety disorder, shortness of breath, and malignant neoplasm of the breast, with a BIMS score indicating intact cognition. Care plan interventions directed staff to allow the resident to voice needs and concerns, avoid arguing with delusions, redirect the resident to a quiet area if escalating, offer reassurance, and interact in ways that built rapport and monitored for precursors to socially inappropriate behaviors. Despite these interventions, during a snack pass the resident became involved in a yelling and screaming incident with a dietary staff member in the dining room.

According to the facility’s investigation and staff interviews, the dietary staff member was seen and heard on camera yelling and screaming at the resident in front of other residents, shouting profanities and using vulgar and offensive references. A CMA reported hearing the dietary staff member call the resident an expletive and described the staff member attempting to get in the resident’s face, prompting the CMA to step between them and remove the resident from the hostile environment. The CMA stated the resident was not getting into anyone’s face or going after staff and that the resident had only asked for more food when the dietary staff member yelled at her. Administrative staff confirmed that camera audio captured the dietary staff member calling the resident an expletive and that staff had to intervene.

The resident later stated she remembered the incident, recalled that she was only asking for more food when she was yelled at, and reported that being yelled at by staff was nothing new or out of the ordinary, stating she was yelled at all the time and did not feel safe when this occurred. The facility’s investigation documented that the resident admitted she shouted back at the staff member and that staff intervened and helped calm her down and support her. The investigation noted that the staff member’s behavior, as seen on camera, was not accepted by the facility. The facility’s abuse prevention policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included verbal abuse. The surveyors determined that the facility failed to ensure the resident remained free from verbal abuse, and this failure placed the resident in immediate jeopardy.

The investigation and record review also showed gaps in follow-up related to the incident. The facility’s investigation did not include any staff witness statements, despite identification of a direct witness. The resident’s EMR lacked evidence of any follow-up psychosocial assessments or documented staff interviews with the resident related to the incident. One social services staff member stated she was not aware of the details of the incident and had not completed any psychosocial follow-up. Another social services staff member reported speaking with the resident the next day and performing generalized verbal check-ins but did not document these interactions and did not conduct or record a formal psychosocial assessment related to the event. Administrative staff stated there was no additional staff education completed after the incident because the involved staff member was terminated and other staff had prior ANE training.

Removal Plan

• Conduct interviews with each resident to identify if any residents were having adverse outcomes due to staff yelling and shouting profanities and/or any other incidents that may have gone unreported.
• Educate all staff that shouting profanities, calling residents vulgar names, or acting in any other excessive, obtuse, obscene, or nonsensical way would not be permitted at the facility.
• Complete Abuse, Neglect, and Exploitation training with staff, with an emphasis on their duty to report.