F0610

E

Failure to Recognize, Report, and Investigate Alleged Verbal Abuse and Protect Resident

Santee, California Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize, respond to, and report an allegation of verbal and psychological abuse toward a resident, and to protect residents during the investigation. A cognitively intact resident with quadriplegia, as documented by an MDS BIMS score of 15/15 and a diagnosis of quadriplegia due to a motor vehicle accident, reported that a CNA became verbally aggressive when she asked him to retrieve food from the refrigerator. According to the resident, the CNA demanded that she say hello if she wanted something from him, repeated this in an angry manner, then yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA. The resident stated the CNA then charged toward her with his chest out and aggressive arm movements in a manner that appeared as if he wanted to physically fight her, causing her to feel scared and defenseless due to the slow speed of her electric wheelchair.

Another resident witnessed the incident and corroborated the reporting resident’s account. Staff who responded immediately after the incident, including a charge nurse and another CNA, observed the reporting resident to be very shaken, visibly in distress, tense, and shaking, and the resident told them she was scared and did not feel safe with the CNA involved. The resident called for help, asked staff not to leave her alone, and reported that the CNA’s raised voice, intimidating body language, and threatening posture made her feel unsafe. One CNA later stated that the resident reported feeling fatigued, refusing to get up, and not socializing after the incident, and that she considered what happened to be abuse.

Despite these observations and statements, the facility’s administrative response did not follow its abuse policy or regulatory requirements. The administrator, who was also the abuse coordinator, stated she only interviewed the CNA involved and did not interview the resident, and that she did not consider the incident to be abuse. The administrator reported that nursing supervisors did not tell her the resident was scared or that this was an abuse allegation, and she believed the resident chose to file an internal grievance instead of requesting that the incident be reported to the state agency. A nursing supervisor acknowledged that she reported only the CNA’s version of events to the administrator, did not relay the resident’s statement, and could not remember what the resident had told her. The facility’s records showed that the CNA continued to provide resident care on subsequent days, and there is no indication in the report that the facility implemented protective measures such as removing or reassigning the CNA while the incident was being investigated, contrary to the facility’s abuse policy and the State Operations Manual requirements to prevent further potential abuse and thoroughly collect evidence.