F0610

D

Failure to Investigate Alleged Verbal Abuse and Missed Dressing Change

Oregon, Ohio Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to investigate an allegation of verbal abuse toward a resident and related failure to provide ordered care. The resident had diagnoses including cervical spinal stenosis, osteomyelitis, type II diabetes mellitus, and muscle weakness, with intact cognition and dependence on staff for toilet hygiene, personal hygiene, and transfers requiring two-person assistance and a mechanical lift. On the date in question, an RN asked a CNA to transfer the resident to bed for dressing changes. The RN later reported that the CNA told her the resident refused to get into bed and that the CNA stated she told the resident, "you made the mess on the bed, you can clean it up," and did not assist the resident in cleaning off the bed or transferring to bed. As a result, the resident’s dressing changes were not completed as ordered that day.

The RN texted this information to the ADON that evening, reporting the CNA’s alleged statement and refusal to help. The ADON acknowledged receiving the text, stated she did not feel the statement was verbal abuse, and took no further action at that time, including not reporting the concern to the DON and not initiating an investigation. The facility’s abuse policy required an immediate investigation when there is suspicion or a report of abuse, neglect, or exploitation, including identifying and interviewing all involved persons and documenting the investigation. The DON later confirmed that the allegation of verbal abuse should have been promptly reported and investigated. Review of the resident’s record showed no progress notes regarding the alleged verbal abuse during the relevant period, and the resident confirmed her dressing was not changed as ordered on the date in question.