F0600

D

Failure to Protect Residents From Verbal and Physical Abuse by Nursing Staff

Wayland, Michigan Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from verbal and physical abuse by nursing staff. One cognitively intact resident with a BIMS score of 13 reported that a night-shift RN told him he did not need oxygen, said “f*** you, I hate you,” and gave him the middle finger during a late-night interaction. The resident stated this was the first time the RN had used that specific profanity toward him, but that the RN had previously told him he did not like him. The resident’s roommate, who also had a BIMS score of 13, corroborated hearing the RN and the resident arguing and hearing the RN use a curse word and say “I hate you.” Facility documentation, including the facility-reported incident and complaint forms, identified this as an allegation of verbal abuse by the RN, and the facility concluded that verbal abuse had occurred based on the resident’s report and the roommate’s confirmation.

A second deficiency involved physical and verbal abuse of another resident by an LPN. This resident had chronic pain, anxiety, dementia, and a BIMS score of 9, indicating moderate cognitive impairment, and was care planned for impaired communication and potential verbal aggression related to dementia, depression, and poor impulse control. On the evening in question, the resident was pacing the hallway as was her usual pattern. According to the LPN involved, she approached the resident at another nurse’s medication cart, asked the resident to give the other nurse space, and then, after the resident turned and began swinging at her, she got behind the resident and guided her to her room with her hands around the resident’s arms. The LPN stated the resident went into her room, continued pacing, and voiced intent to leave, and that she did not yell but had a loud voice.

Multiple staff witnesses provided a different account of the same event, describing escalating verbal and physical actions by the LPN toward the resident. A former CNA reported that the LPN had been rude to the resident earlier, then told the resident she was bothering the other nurse and needed to go to her room. When the resident refused, the LPN escalated, grabbed both of the resident’s wrists, forced her arms together behind her back, and held them up in a way that appeared painful while walking her down the hall. The CNA stated the resident repeatedly yelled “ouch, that hurts” and “get off of me,” and that the LPN “bashed” the resident into a utility closet door and then into the entrance area of the resident’s room before entering the room and slamming the door. The CNA reported hearing further “bashing” noises and the resident screaming “Stop, I can’t breathe,” and later observed the resident visibly shaken, crying, with disheveled hair, and reporting that the LPN had choked her and thrown her to the ground.

Another LPN witness stated that the resident had been calmly standing and chatting at her med cart, which helped the resident’s anxiety, and that the resident was not being disruptive when the involved LPN approached and told the resident the nurse did not want her bothering her. According to this witness, the resident laughed, which appeared to escalate the LPN, who then loudly insisted the resident go to her room. When the resident refused and attempted to strike the LPN, the LPN grabbed the resident’s arms, “whipped” them behind her back, and walked her toward her room while the resident yelled that she was being hurt and tried to break free. This witness also described the LPN picking up the resident and slamming her into the utility closet door, then taking her toward her room, after which loud bashing noises and the resident’s yelling were heard from the room. Both this LPN and the CNA reported seeing the LPN slam the resident’s door on her twice as the resident tried to exit, while yelling at her to stay in her room, and hearing the LPN say she would “fight” the resident.

Additional corroboration came from the receptionist, who encountered the resident shortly after the incident. The receptionist described the resident speed walking, crying, and saying she had just gotten into a fight. When the receptionist attempted to escort the resident back toward her room, the resident became more distressed and said she did not want to go down that hallway because she did not want another fight. The receptionist observed the resident’s hair was messed up and that she appeared very shaken, and reported that the resident said the LPN had grabbed her by the shirt and thrown her down. The administrator later confirmed that, based on witness interviews, she substantiated that the LPN had verbally and physically abused the resident. Together, these events demonstrate that the facility failed to ensure residents were free from verbal and physical abuse by staff, as required by its abuse policy and resident rights.

The facility’s own investigation documents characterized the LPN’s conduct as verbal and physical abuse and noted that the LPN did not use de-escalation skills and that her frustration intensified the situation. The resident involved had known behavioral and communication needs, including dementia and a history of pacing and anxiety, and the care plan called for specific communication and de-escalation strategies such as not rushing, using simple cues, and providing verbal and physical cues to alleviate anxiety. Despite these identified needs and interventions, the LPN’s actions, as described by multiple witnesses and the resident, involved forceful physical handling, painful arm positioning, slamming into doors, door slamming to confine the resident, and threatening statements, all of which constituted abuse and a failure to follow the resident’s care plan and the facility’s abuse policy.

In both cases, the residents and witnesses were considered by the administrator and social worker to be reliable historians without a known history of making false allegations. The facility’s own documentation and interviews with leadership acknowledged that verbal abuse occurred in the first case and that verbal and physical abuse occurred in the second case. These findings establish that the facility did not protect residents from all types of abuse by staff, including verbal and physical abuse, as required by regulation and by the facility’s own abuse policy, resulting in residents being subjected to abusive language and physically abusive handling by nursing staff.