F0600

D

Failure to Protect Resident From Verbal and Emotional Abuse During Toileting Assistance

Springfield, Missouri Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively intact resident from verbal and emotional abuse during toileting and transfer assistance. The resident, who had diagnoses including thoracic spondylosis, hyperlipidemia, and osteoporosis, required partial to moderate assistance with transfers and toileting and was totally dependent on one staff member for toilet use. During a night shift, the resident used the call light for assistance to the bathroom. CNA B responded, accompanied by CNA E, and assisted the resident out of bed and into a wheelchair. During this process and the subsequent transfer back to bed, the resident repeatedly reported pain, including when the resident’s leg and foot became caught in the wheelchair, but CNA B continued the transfer.

The resident reported that CNA B was rough, rude, and loud, and that the aide “flopped” the resident into the chair and continued care despite the resident’s complaints of pain and statements that the foot was caught. The resident stated that after being returned to bed, CNA B squatted down between the resident’s bed and the roommate’s bed, got close to the resident’s face, and told the resident that if the resident did not transfer independently, the resident would be put on a bed pan. The resident refused the bed pan and later described feeling scared to use the call light again that night, remaining quiet and delaying further toileting needs until day shift staff were on duty. The resident also reported hearing other residents saying “you are hurting me” and “that hurts” after the incident and expressed not wanting CNA B to return to the room.

Multiple witnesses corroborated aspects of the resident’s account. The roommate reported hearing banging during the transfer, seeing CNA B yank back the bed covers and throw pillows, and observing from the resident’s facial expression that the resident was in pain, as well as seeing CNA B squat between the beds. CNA E, who was shadowing CNA B and standing at the doorway, stated that CNA B was rude and aggressive, continued the transfer after the resident said “you are hurting me,” and argued with the resident about using a bed pan, prompting CNA E to suggest they leave the room due to discomfort with CNA B’s behavior. Other CNAs reported that the resident told them CNA B had been rough, hateful, and rude, had tried to make the resident use a bed pan, and had said the resident would have to use a bed pan if the resident did not get up independently. An LPN who witnessed the resident’s later report described the resident’s voice as quivering and characterized the interaction as abuse based on its impact on the resident. These actions and statements by CNA B, in the context of the resident’s dependence for toileting and transfers and repeated pain complaints, constitute the basis for the cited abuse-related deficiency.

CNA B’s own written and verbal statements acknowledged that the resident complained of pain during transfers, that the resident’s foot became caught under or in the wheelchair, and that a bed pan was suggested as an alternative because the resident was not assisting with transfers. However, the resident’s and witnesses’ descriptions emphasized that CNA B continued the transfer despite the resident’s pain complaints and used threatening and demeaning language about forcing the resident to use a bed pan if the resident did not transfer independently. The facility’s own policies defined abuse as including intimidation and actions causing mental anguish and stated a goal of maintaining an abuse-free environment. The events described, including the aggressive manner of care, continuation of care despite pain complaints, and degrading statements about bed pan use, led surveyors to identify a failure to protect the resident’s right to be free from verbal and emotional abuse.