F0610

D

Failure to Thoroughly Investigate Alleged Physical Abuse Incident

Milwaukee, Wisconsin Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate an alleged incident of physical abuse involving resident R6 and CNA-BB, as required by the facility’s Abuse Prevention Program policy. R6, who has PTSD and a BIMS score of 15 indicating intact cognition, alleged that CNA-BB grabbed R6’s arm and that R6 felt CNA-BB’s nails on the skin. The facility’s policy requires that the individual conducting an abuse investigation interview the person reporting the incident, any witnesses, and staff on all shifts who had contact with the resident during the period of the alleged incident. The facility’s investigation conclusion stated that it was unable to conclusively determine that a scratch was from physical contact between R6 and CNA-BB due to varying statements, but that it was prudent to deduce the scratch occurred from the CNA making contact with the resident’s arm.

Despite these requirements, the investigation did not include an interview or statement from LPN-AA, who first received R6’s report of the alleged abuse and notified the NHA and DON, nor from CNA-CC, an agency CNA who reported witnessing the interaction between R6 and CNA-BB and stated having explained what happened to the nurse on duty. LPN-AA reported that, after being informed by R6 of the alleged arm grabbing, LPN-AA contacted the NHA and DON and was instructed by the NHA to obtain a resident statement and perform a skin check, which was done and provided to the NHA. CNA-CC confirmed caring for R6 on the date of the incident and stated that the facility did not contact CNA-CC for a statement about the alleged incident. The surveyor confirmed that the facility’s submitted investigation lacked statements or interviews from both the reporting nurse and the witnessing CNA, and the NHA acknowledged that a statement from CNA-CC was not obtained.