F0600

G

Failure to Protect a Vulnerable Resident From Physical and Verbal Abuse by a Nursing Assistant

Plymouth, Minnesota Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a vulnerable resident from staff-to-resident abuse by a nursing assistant (NA-A). The resident had a history of stroke, cancer with a prognosis of less than six months to live, hemiplegia and hemiparesis affecting one side of the body, aphasia, dysphagia, a prior neck of femur fracture, depressed mood, restlessness, and anxiety. The admission MDS documented severe cognitive impairment, no mood or behavioral issues at baseline, and dependence on staff for ADLs, with bladder and bowel incontinence. The care plan identified the resident as a vulnerable adult expected to decline due to end-of-life status, required assistance with incontinent care and transfers, and directed staff to use a calm, consistent approach, monitor for pain and emotional status, avoid overstimulation, and maintain an environment free of abuse, neglect, and exploitation.

On the date of the incident, video footage showed the resident lying in bed wearing only an incontinent pad and partially covered by a sheet. NA-A removed a clean incontinent pad from under the resident’s pillow and tossed it on the floor, then used her hip to push the bed toward the wall. The resident, in a soft voice, said “no, no, no” while looking at the pad on the floor. NA-A told the resident he already had one on his body and did not need the extra pad. NA-A then grabbed the resident’s call light, moved to the other side of the bed, and when the resident raised his left hand, she hit his hand with the call light and told him to stop before plugging the call light into the wall and stating she was trying to help him. She then lowered the bed to the floor and placed the bed remote on the bedside dresser handle, out of the resident’s immediate reach.

The video further showed that as NA-A picked up items from the floor, the resident pointed and faintly said “here, here, here,” indicating the area where the pad had been thrown. Standing at the foot of the bed, NA-A dropped a clear bag on the floor, raised and lowered her right hand, extended her middle finger toward the resident three times, and stuck her tongue out at him. She walked past him mocking him with facial expressions while picking up dirty linen. The resident pointed his finger and said “no, no, no,” after which NA-A left the room and the resident began crying, placed his left hand over his forehead, and appeared visibly upset. He struggled to reach the bed remote on the nightstand handle to raise his bed. When NA-A re-entered, she made grunting sounds mimicking the resident, threw a bedspread over him, lowered the bed back to the floor, placed the bed remote inside the bedside stand, and left the room with the lights on, without addressing or speaking to him. The resident again struggled to reach the remote and remained lying on his side looking at the floor with the bed in the lowered position.

Family interviews corroborated the impact of the incident on the resident. One family member reported that she monitored a camera in the resident’s room, noticed his bedding torn apart, and called the facility for assistance, then observed the abusive interaction on the camera. She explained that the resident liked to keep an incontinent pad under his pillow to try to change himself and that he became very upset when NA-A took it away and threw it on the floor. She stated he briefly cried because of how he was treated and his inability to communicate or speak up, and that he felt angry, frustrated, then defeated, and ultimately very upset and tearful when NA-A flipped him off. Another family member stated the incident made the resident more distrustful of staff and withdrawn, and that in the moment it made him cower and cry, and she believed he felt disrespected, helpless, and in physical danger. The facility’s abuse prevention policy stated that maltreatment of residents, including abuse and neglect, would not be tolerated and that all employees were responsible for ensuring residents were free from maltreatment, but the actions of NA-A toward this resident constituted physical and verbal abuse contrary to that policy.

The facility’s written Abuse Prevention and Prohibition policy, reviewed in 2022, specified that the facility would not tolerate maltreatment of residents, including abuse and neglect, and that all employees were responsible for assuring residents were free of maltreatment. It also stated that the facility would not knowingly employ individuals who had been convicted of abusing, neglecting, or mistreating individuals, and that reports of maltreatment would be promptly and thoroughly investigated. Despite these written expectations, the documented and observed conduct of NA-A toward this resident—throwing his clean incontinent pad on the floor, hitting his hand with the call light, mocking him with gestures and facial expressions, extending her middle finger at him multiple times, mimicking his vocalizations, and placing the bed and remote out of his reach while he cried and was visibly upset—constituted the abusive actions and inactions that led to the cited deficiency for failure to protect the resident from abuse.