F0609

D

Failure to Timely Report Allegation of Rough Care and Threatening Behavior

Marshfield, Missouri Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The facility failed to timely report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two hours after staff became aware of the allegation. The facility’s abuse policy required that any suspicion or knowledge of abuse, neglect, or misappropriation be reported immediately to the Administrator and charge nurse, and that the Administrator, DON, or designee begin an internal investigation immediately and report to DHSS within two hours if the allegation involved serious injury, or within 24 hours if it did not. A resident with multiple sclerosis and minimal cognitive impairment, admitted on 02/02/24, reported that a CNA had been rough during incontinence care and had punched the wall above the resident’s head, causing the resident to feel fearful and not want that CNA to return.

In the early morning hours, between approximately 2:00 A.M. and 2:25 A.M., a CNA entered the resident’s room to provide care and was informed by the resident that another CNA had turned on a bright light while the resident was sleeping, was rough while attempting to change the resident, and, after being told to stop, punched the wall three times above the resident’s head before leaving. The CNA immediately reported the incident to the charge RN, wrote a statement, and attempted to notify the DON and Administrator by phone and text, including sending photos of the written statement. The charge RN acknowledged being informed between 2:00 A.M. and 3:00 A.M. that the resident complained of rough care and that the CNA had punched a wall, reassigned staff so the alleged CNA would not return to the room, but did not report the allegation to the DON or Administrator, believing that “rough with cares” was not an allegation of abuse.

Despite the CNA’s attempts to contact leadership during the night, the DON and Administrator did not respond at that time, later stating they had been sleeping and did not hear their phones. The Administrator did not confirm the incident with staff until later that morning and did not submit the online report to DHSS until 9:58 A.M., more than seven hours after staff first became aware of the allegation. Facility records showed no progress note documentation of the allegation in the resident’s chart. Interviews with other nursing and CNA staff indicated they understood that rough care and a resident not feeling safe should be treated as an abuse allegation and reported immediately, and both the DON and Administrator acknowledged that rough care and punching a wall constituted abuse that should be reported to the State within two hours. The delay in reporting and lack of timely notification to DHSS constituted the deficiency.