F0600

G

Failure to Prevent Verbal Abuse and Threatened Involuntary Seclusion of Residents

Richmond, Indiana Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from mental and verbal abuse and threats of involuntary seclusion, resulting in fear, intimidation, and mental anguish for two cognitively intact residents. Resident B had diagnoses including bipolar disorder, anxiety, paranoid schizophrenia, dementia, and a history of repeated falls, and used a wheelchair for mobility. On a night in early January, Resident B exhibited paranoid and accusatory behaviors, yelling and screaming in her room and the hallway, and threatening staff, leading to her transfer to the hospital. The nurse’s progress note documented these behaviors and the decision to send the resident out, but did not document any fall or attempt at seclusion.

CNA witnesses later reported that during this same behavioral episode, RN 5 attempted to have Resident B placed in a supply closet behind the nursing station. CNA 6 stated that RN 5 asked CNA 5 to put Resident B in the supply closet, and when CNA 5 refused, RN 5 told both CNAs not to say anything about what happened. CNA 5 reported that RN 5 tried to get her to push the resident’s wheelchair into the supply closet while RN 5 held the door, and when she refused, RN 5 grabbed the wheelchair and the resident fell to the floor. CNA 5 and CNA 6 reported that RN 5 instructed them not to help the resident, but CNA 6 assisted Resident B back into her wheelchair and they kept the resident away from RN 5 until EMS arrived. LPN 8 reported that CNA 5 had informed her that RN 5 tried to have Resident B involuntarily secluded in the supply closet and that the resident had a fall that same night. The supply closet was later observed to be a locked room containing medical equipment, oxygen, supplies, and chemicals, and was not a resident care area.

The deficiency also includes an incident of verbal and mental abuse toward Resident C, who was cognitively intact and had diagnoses including idiopathic pulmonary fibrosis, migraines, and cirrhosis of the liver. Resident C reported that one night she could not find her call light and yelled out for help because she needed repositioning, medications, and assistance back to bed. She stated that RN 5 entered the room and said she did not know what the resident was yelling about but that someone would take care of it, then yelled at her for waking other residents and told her that if she could not be quiet, she needed to be moved to a different floor. Resident C reported that RN 5 told her that the next time she saw her, it better not be on her floor, and that she needed to grow up and stop worrying only about herself, which made the resident cry and feel very small. CNA 4 corroborated that Resident C was yelling for help to have her blood pressure taken so she could receive medications and go to bed, and that RN 5 lectured the resident for being loud and disrupting others, initially refused to take her blood pressure, and initially refused to assist with getting her back to bed. These actions occurred despite the facility’s written policy defining abuse, involuntary seclusion, mental abuse, and verbal abuse, and prohibiting intimidation, unreasonable confinement, and threats of punishment or deprivation.