F0607

D

Failure to Report and Investigate Misappropriation of Medication and Alleged Verbal Abuse

Peru, Indiana Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own policies for reporting and investigating misappropriation of resident property when staff used a resident’s prescription medication for staff personal use. The DON recalled that in October, an LPN instructed an unnamed nursing staff member to give a CNA a dose of Zofran (ondansetron) from a resident’s private medication supply for the CNA’s stomachache. A later text exchange showed the LPN asking if this included the Zofran she had given somebody, followed by emojis, and the DON responding that additional statements were needed. The DON acknowledged she did not obtain written statements from the involved staff and was not aware the incident was reportable, so she did not report the misappropriation to the State Agency. Resident M’s record showed an order for ondansetron 4 mg every 6 hours as needed for nausea and vomiting during the admission period.

The facility also failed to follow its abuse policy by not reporting an allegation of verbal abuse to the State Agency and not conducting a thorough investigation. Resident H had dementia, weakness, anxiety, mild cognitive impairment, no documented negative behaviors, and required substantial to maximal assistance for standing, transfers, and toileting, with care plan interventions including extensive assistance for transfers, use of a walker, and encouragement to stand slowly. On one shift, a QMA reported that a CNA had yelled at Resident H and that the resident was visibly upset and stated he was not okay. The QMA reported hearing the CNA speaking loudly and passive-aggressively to the resident, saying phrases such as “you need to stand up,” “stop doing that,” and “if you don’t stand up I’ll put you in your wheelchair,” and reported this allegation to an LPN and to the Administrator, both verbally and in writing.

Multiple staff statements documented that the allegation of verbal abuse toward Resident H was communicated to supervisory staff, including the LPN and the Administrator. The LPN reported that the QMA told her the CNA was being mean to a resident and that she then notified the Administrator. The QMA stated she specifically reported that the CNA had been verbally abusive to Resident H and to other staff, and that Resident H appeared visibly upset after the interaction. Despite these reports and the facility’s written policy defining abuse (including verbal abuse and intimidation causing mental anguish) and requiring notification to the State Department of Health within 24 hours of becoming aware of an alleged incident, the Administrator stated that the State was not notified because abuse was not identified, and the facility’s investigation concluded with no findings. This sequence of events demonstrates the facility’s failure to implement its abuse, neglect, exploitation, and misappropriation policies regarding reporting and investigation of both the medication misappropriation and the verbal abuse allegation.