F0609

D

Failure to Report Alleged Abuse and Injury to Executive Director

Richmond, Indiana Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to follow its abuse policy requiring that all allegations of abuse be reported immediately, and no later than two hours, to the Executive Director. Resident B, who had diagnoses including bipolar disorder, anxiety, paranoid schizophrenia, dementia, and a history of repeated falls, was cognitively intact for daily decision making per a quarterly MDS dated 12/5/25 and used a wheelchair for mobility. Certified nursing assistants (CNAs) reported that in early January 2026, during an episode when Resident B was yelling and screaming, RN 5 was emotionally abusive, antagonizing, and spiteful toward the resident instead of allowing her to calm down as staff typically did. RN 5 allegedly attempted to have CNAs push the resident, in her wheelchair, into a supply closet, and when the CNAs refused, RN 5 grabbed the wheelchair, resulting in the resident falling to the floor.

CNA 6 reported that she informed the DON about RN 5 trying to get staff to put Resident B in the supply closet and causing the resident to fall, but she did not report the incident to the Executive Director. CNA 5 similarly reported that she informed the Unit Manager about RN 5’s emotionally abusive behavior, the attempt to place the resident in the supply closet, and the resulting fall, and the Unit Manager stated she would report it to the DON. During an interview, the Executive Director stated that no staff had reported that RN 5 requested staff to put Resident B in the supply closet or that RN 5 had caused Resident B to fall. The facility’s abuse policy, provided by the Executive Director, specified that allegations of abuse were to be reported to the Executive Director immediately, but not later than two hours after the allegation was made, which did not occur in this case.