F0600

D

Abusive Verbal Threats and Forced Incontinence Care by RN

Madison, Wisconsin Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by a registered nurse (RN A). Facility policy on preventing abuse, neglect, misappropriation, mistreatment, and exploitation, updated 08/25/2023, states that residents will not be abused by anyone and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy clarifies that "willful" means the individual acted deliberately, even if they did not intend to inflict harm. Resident #1 was admitted on 10/02/2025 with a history of lumbar vertebral osteomyelitis, lumbar discitis, anxiety disorders, muscle weakness, and right thigh pain. An admission MDS with ARD 10/08/2025 showed intact cognition (BIMS 14), dependence on staff for toileting hygiene and rolling in bed, frequent pain that affected sleep, therapy participation, and daily activities, and a pattern of rejecting care on some days. The care plan identified chronic bilateral hip pain related to arthritis and acute back pain related to lumbar osteomyelitis, with interventions to anticipate pain needs and respond immediately to pain complaints, and to check and change the resident frequently due to ADL self-care deficits and limited mobility.

On 10/09/2025, CNAs B and C attempted to provide incontinence care because the resident’s brief was saturated and there were concerns about skin breakdown. Interviews with CNAs B and C indicated that the resident was dependent for most care, incontinent of bowel and bladder, and often verbally refused care due to anxiety and significant back pain, but was not typically physically resistive. CNA C reported that the resident initially agreed to incontinence care but began screaming and asking to be put down when staff attempted to roll them. CNA B stated she left to get the IDON, who was familiar with the resident, while CNA C remained in the room talking with the resident. Both CNAs reported that RN A entered the room, yelled at the resident, and told the resident they would be kicked out of the facility and cut from therapy if they did not allow care. CNA B stated that RN A, without explanation to the resident, forcibly pulled the resident onto their side, during which the resident screamed and cried in pain and asked to be let go, while RN A continued to lecture and yell. CNA B estimated the resident was held on their side for 8–10 minutes while in pain, and then forcibly rolled to the other side so that incontinence care, ointment application, and a clean brief could be completed.

CNA C corroborated that RN A ran into the room, screamed at the resident about being kicked out if they did not accept care, and rolled the resident onto their side without permission, directing CNA C to hurry and clean the resident while the IDON stood in the room observing. The IDON stated she heard the resident screaming and went to the room a couple of minutes later, where she observed RN A bullying the resident, telling them they would be kicked out of the facility and that therapy would stop if the resident did not do what RN A said. The IDON described the resident as very anxious and fearful of rolling, and recalled seeing CNAs on either side of the resident while RN A was in the resident’s face yelling. The IDON stated she left the room while staff were turning the resident but later returned to reassure the resident. An internal mistreatment/abuse report documented that RN A leaned over the resident, pointed, and stated, "I'm not going to keep doing this with you, you need to be getting out of the bed at least twice a day, and you need to knock this off or you're going to be cut from therapy and kicked out next week," while the resident was crying, upset, and in pain throughout the interaction. The facility’s Executive Director later stated that RN A should not have lectured the resident or forced incontinence care against the resident’s will, and the facility substantiated the allegation of abuse.

In contrast, RN A stated in a telephone interview that the resident had bone pain from infection, was often resistant to care and to using a full-body mechanical lift, and that pain was a major issue causing the resident to cry when turned. RN A reported that a physical therapist had informed her that a care conference would be held to discuss stopping therapy due to lack of progress, and she went to the resident’s room to motivate them to participate in therapy. RN A claimed no other staff were present when she spoke with the resident, that she only reiterated what therapy had told her about possible discontinuation of therapy, and that she did not tell the resident they had to participate in therapy to stay in the facility or that they would be thrown out. RN A stated she did not recall assisting with care for the resident on that date and did not believe she had done anything wrong. However, multiple staff interviews and the internal report consistently described RN A verbally berating the resident, threatening discharge and loss of therapy, and forcibly rolling and holding the resident in painful positions against their will during incontinence care, resulting in unnecessary pain and anxiety for the resident.