F0600

G

Failure to Protect Resident From Verbal and Alleged Physical Abuse During Behavioral Episode

Chicago, Illinois Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively intact resident from physical and verbal abuse by staff. The resident had multiple diagnoses including COPD, bipolar disorder, suicidal ideations, hypertensive heart disease without heart failure, hepatitis C, schizoaffective disorder, and alcohol abuse, and had a BIMS score of 15 indicating intact cognition. On a night shift, the resident exhibited escalating behaviors, including agitation, attempts to elope, and calling police about people on the roof with guns. Staff, including an LPN not assigned to the resident, became involved in managing these behaviors, and police and emergency services were called to the facility.

During this episode, multiple witnesses described a verbal altercation between the resident and an LPN. Two other residents reported hearing the resident call the nurse a derogatory term and hearing the LPN respond with similarly derogatory language, including statements such as “Calm your a** down. Your momma’s a B*” and “Your momma B*.” The resident herself reported that she called the nurse a B* and that the nurse called her a B* back. The facility’s own investigation substantiated that the LPN used foul and inappropriate language toward the resident, and the DON and Administrator acknowledged that such language constitutes verbal abuse under the facility’s abuse policy, which prohibits disparaging and derogatory terms directed at residents.

The resident also alleged that during the physical tussle associated with attempts to control her behavior and arrange transport to the hospital, the LPN pulled her braided hair, resulting in several braids being forcibly removed from the crown of her scalp. The resident showed surveyors a bald area on the crown of her head and a plastic bag containing six individual braided strands with hair attached, stating these were pulled out by the LPN during the incident. Another resident reported hearing the resident say, “Let my hair go, B*,” directed at the nurse, and hearing the nurse respond with a derogatory remark, though this witness did not visually confirm the hair pulling. The LPN denied pulling the resident’s hair but acknowledged that if staff pull a resident’s hair it is physical abuse, and the facility’s physician stated he agreed with termination when informed of the hair-pulling allegation and that such an act can cause pain and injury. The facility’s abuse policy affirms residents’ rights to be free from physical and verbal abuse, including physical acts such as hitting and controlling behavior, and verbal abuse defined as disparaging or derogatory language, and the events described demonstrate a failure to uphold these protections for this resident.

The facility’s documentation and interviews show that the resident reported head pain and described a fight with the nurse before being sent to the hospital, specifically stating that the nurse pulled her hair out from the top of her head and that her head remained sore. The resident reported feeling disrespected, humiliated, and embarrassed by the incident. Staff interviews confirmed that the resident reported hair pulling and showed staff the bag of braids she said were pulled out. The Administrator, acting as abuse coordinator, acknowledged that if a resident’s hair is pulled by staff, it is considered physical abuse, and that the resident showed her the top of her head and a braid said to have been removed. Despite some conflicting accounts about the exact sequence of events and whether hair pulling was directly observed, the combination of the resident’s consistent statements, physical evidence presented (bald spot and braids), and corroborating witness accounts of the verbal exchange establish that the resident was not kept free from verbal and alleged physical abuse as required by the facility’s abuse policy and regulatory standards.