F0609

D

Failure to Immediately Report Alleged Abuse of a Cognitively Impaired Resident

Stillwater, Oklahoma Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The facility failed to ensure an allegation of abuse was immediately reported as required by its policy. The facility’s undated “Patient Abuse” policy stated it was strictly prohibited for any employee to fail to immediately report an incident of patient abuse to the Administrator or DON. Resident #1, admitted on 01/25/26, had severely impaired cognition with a BIMS score of 03, diagnoses including dementia, and was dependent on staff for transfers and required substantial/maximal assistance for wheelchair use. An incident report dated 02/12/26 documented an allegation of abuse that occurred on 02/11/26 at approximately 11:00 p.m., when RN #1 observed CNA #1 behave in an abusive manner toward Resident #1.

Family member #1 reported they had been called to the facility around 10:30 p.m. to 11:00 p.m. because Resident #1 was being combative with care and requested the resident be transferred to a couch where they had been sleeping recently. Family member #1 stated CNA #1 yanked the resident up from the wheelchair and dropped them down on the couch with force, and they felt the CNA’s actions were abusive. RN #1 stated they had asked CNA #1 to transfer Resident #1 from the wheelchair to the couch in the common area, and that CNA #1 was mad and aggressively transferred the resident. RN #1 stated they and family member #1 both felt the CNA’s actions were abusive, but RN #1 did not report the incident to the DON until 6:00 a.m. the next morning, rather than immediately. The administrator stated they reported the abuse allegation and started an investigation as soon as they were made aware of the incident by RN #1, and the DON stated the incident should have been reported to them or the administrator immediately by RN #1.