F0600

D

Failure to Protect Resident From Verbal Abuse and to Investigate Abuse Allegations

Indianapolis, Indiana Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from verbal abuse and to recognize and investigate an allegation of abuse involving two roommates. Resident C, who was cognitively intact and required staff assistance with mobility, dressing, transfers, and personal hygiene, was admitted with diagnoses including a history of malignant brain neoplasm, muscle weakness, depression, and a need for assistance with personal care. After Resident B, who had a documented history of bipolar disorder and recent escalating behaviors including verbal aggression, verbal abuse of a roommate, and spraying a substance at a CNA, was sent to a psychiatric facility, Resident C used the landline phone in their shared room to communicate with her sister because her cell phone and charger were not working. When Resident B returned from the psychiatric facility, she became upset that Resident C was using the landline phone and an argument ensued.

During this argument, Resident C reported that Resident B told her, "if anyone touches my stuff, I'm going to kill you," and also told Resident C’s sister over the phone that she was going to kill her as well. Resident C indicated to staff that Resident B kept threatening her, and Resident C’s sister confirmed hearing Resident B say that if she called the phone again, she would kill her, and that she heard Resident B tell Resident C, "If you touch my things, I will kill you. I will kill anyone who touches my things." CNA 5 responded to the roommates’ call light and heard Resident C say she needed to get out of the room because Resident B was being mean and kept threatening her; CNA 5 then reported the allegation to the Unit Manager. Despite these reports, the DON later stated she believed the incident was only an altercation between Resident B and Resident C’s sister and did not involve resident-to-resident abuse, and therefore no abuse investigation was initiated.

Resident C reported that she remained fearful of Resident B after the incident, stayed in her room, and did not attend activities because of her fear. She stated that when Resident B walked by her door, Resident B would look at her and make a finger gun gesture. Resident C reported this behavior to the SSD, who acknowledged being told that Resident B would walk by Resident C’s room and make a finger gun gesture, but the SSD did not interview staff about these gestures and indicated she had not personally observed them. The SSD also indicated she had witnessed Resident B being verbally aggressive with other residents in the past but did not know her to have threatened to kill anyone and was unsure if the DON had been informed of the threats. The DON stated she was unaware of any threats to kill Resident C, was not aware that APS had been notified or that police were supposed to have been contacted, and did not consider the situation to be resident abuse, so she did not conduct staff or resident interviews. This sequence of events, combined with the facility’s own policy defining mental or verbal abuse as conduct causing or having the potential to cause fear or intimidation, led to the finding that the facility failed to protect Resident C’s right to be free from verbal abuse and failed to appropriately identify, report, and investigate the alleged abuse.

The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and defined mental or verbal abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, or agitation. Despite this policy and the known behavioral history of Resident B, including documented episodes of verbal aggression and verbal abuse of a roommate prior to this incident, the DON indicated she believed Resident B did not have a prior history of resident agitation or concerns that would preclude assigning her a new roommate. The DON also indicated that, because she believed the incident involved only Resident C’s sister, she did not treat it as an abuse allegation and did not initiate an investigation or report it to the state agency within two hours as would have been required if she had known of threats to kill Resident C. As a result, the facility did not fully recognize or respond to the reported threats and intimidating gestures directed at Resident C, and did not ensure that the resident was protected from verbal abuse as required by regulation and facility policy.