F0610

D

Failure to Enforce Staff Suspension After Abuse Allegation

Madison, Wisconsin Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its abuse prevention policy by not effectively suspending and excluding an alleged abuser from the premises during an ongoing abuse investigation. The facility’s written policy on abuse, neglect, misappropriation, mistreatment, and exploitation, updated on 08/25/2023, states that residents will not be abused by anyone and that the first responsibility of the facility is to assure resident safety. The policy further requires that, in the event of an allegation of abuse against a staff member, the facility must take immediate steps to ensure resident safety and prevent further harm, including at a minimum the suspension of the staff member until the investigation is complete. Despite this policy, the facility allowed the alleged abuser, a registered nurse (RN A), to re-enter and be present in the facility on multiple days after an abuse allegation was reported.

Resident #1 was admitted on 10/02/2025 with a medical history that included osteomyelitis and discitis of the lumbar region, anxiety disorders, muscle weakness, and right thigh pain. An admission MDS with an ARD of 10/08/2025 showed a BIMS score of 14, indicating intact cognition, and documented that the resident rejected care on one to three days during the assessment period. The MDS also indicated the resident was dependent on staff for toileting hygiene and rolling, and experienced frequent pain that affected sleep, therapy participation, and day-to-day activities. The care plan identified chronic bilateral hip pain related to arthritis, acute back pain related to lumbar osteomyelitis, and an ADL self-care deficit related to activity intolerance, limited mobility, and hospice services, with interventions to anticipate pain needs and check and change the resident frequently.

On 10/09/2025 at approximately 5:00 PM, the Interim DON observed RN A telling Resident #1, "you just need to knock it off or therapy will cut you and we will throw you out," and an abuse allegation was reported by the Administrator on 10/10/2025 at 11:00 AM. The report indicated RN A had completed her shift, left the facility, and was suspended; however, facility records showed RN A clocked in and was present in the facility on 10/11/2025, 10/12/2025, and 10/13/2025 during the ongoing investigation. Interviews revealed that RN A stated she was not informed of her suspension until 10/13/2025 while working on the 3rd floor, and that she had come in to work a shift and to complete online training and return keys. The Interim DON confirmed RN A came in the weekend after the incident to complete online training, and the Administrator stated he was unaware of RN A’s presence on 10/11/2025 and 10/12/2025 and that there was no way to suspend a staff member’s timecard or alert other staff to the suspension. As a result, the facility did not implement effective protections after the allegation of abuse involving RN A and Resident #1, allowing RN A access to residents during the investigation.