F0609

E

Failure to Timely Report Allegation of Verbal Abuse in Secured Behavioral Unit

Toledo, Ohio Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident on the secured behavioral unit. The resident had diagnoses of schizophrenia, PTSD, anxiety, and depression, and a quarterly MDS documented moderate cognitive function, verbally abusive behaviors, and frequent rejection of care. On the evening of 01/03/26, a nursing progress note by an LPN described an altercation in the dining room between the resident and a CNA over returning a meal tray to the food cart. The note stated that the resident became upset, got into the CNA’s face, and spoke with an aggressive attitude, while another CNA intervened and escorted the resident out to calm down. The note indicated that the unit manager and physician were notified, but there was no indication that the incident was treated or reported as a possible abuse allegation at that time.

Subsequently, on 01/13/26, the unit manager accompanied the resident to an appointment where the resident reported to the provider that an aide had gotten in her face a few days earlier. Upon returning to the facility, the unit manager reported this as a possible allegation of abuse, and an investigation was initiated. During the investigation, the social worker interviewed the resident and learned that the resident experienced emotional distress from the 01/03/26 dining room incident. The resident reported that the CNA stood in close proximity, raised her voice, and demanded that the resident return her meal tray, which the resident perceived as abusive. The investigation also revealed that the resident had left a voicemail on the admissions manager’s phone line on 01/05/26 describing the incident, but this voicemail was not identified or acted upon until 01/14/26.

Video surveillance of the dining room on 01/03/26 showed the resident eating with another resident, then standing up and walking away from the table as two CNAs sat nearby looking at their phones. After one CNA said something to the resident, the resident approached the CNA, and both were seen flailing their arms and pointing fingers at each other in an aggressive manner, with the CNA in close proximity and using assertive body language. The resident appeared visibly distressed and was observed crying before the second CNA stepped between them and led the resident out of the dining room. Staff schedules confirmed that the involved CNA continued to work multiple shifts on the secured behavioral unit between the date of the incident and the date the administrator became aware of the allegation. The administrator acknowledged that the CNA should have handled the situation differently and confirmed that the LPN who documented the incident on 01/03/26 should have reported it as an allegation of abuse at that time, in accordance with the facility’s abuse policy requiring immediate reporting of alleged violations of abuse.

The facility’s abuse, neglect, and exploitation policy required that all alleged violations of abuse be reported to the administrator, state agency, Adult Protective Services, and other required agencies immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury, and no later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. In this case, the initial altercation and the resident’s distress were documented on 01/03/26, and the resident attempted to report the incident via voicemail on 01/05/26, yet the incident was not reported as a possible abuse allegation to the administrator and state agency until 01/13/26. During this period, the CNA involved continued to work on the unit. The administrator verified that the delay in recognizing and reporting the incident as an abuse allegation, including the failure of the LPN to report it on 01/03/26 and the missed voicemail from 01/05/26, constituted a failure to ensure timely reporting of an allegation of abuse as required by facility policy.