F0609

D

Late Reporting of Verbal Abuse Allegation to State Agency

Alexandria, Minnesota Survey Completed on 03-26-2026

Penalty

Fine: $19,330

Summary

The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the State Agency (SA) within the required two-hour timeframe after suspicion of abuse was formed. On the evening in question, a nursing assistant (NA-A) was assisting a cognitively impaired resident (R1) with evening cares when multiple staff observed and later reported that NA-A used a loud, stern, and verbally aggressive tone toward the resident. Statements attributed to NA-A included telling the resident to stop crying and that she was acting like a two-year-old, threatening that if the resident hit her again she would hit the resident back, saying the resident was in trouble and might be sent to a locked unit, and stating that nobody would want to work with a “crybaby.” Staff present perceived these interactions as verbally abusive and threatening. R1, who had severely impaired cognition, dementia, Alzheimer’s disease, depression, anxiety, and a psychotic disorder, was crying, distraught, and had just ended a phone call with her son during which she expressed a desire to leave the facility.

R1’s admission MDS and care plan documented significant cognitive impairment, mood disturbance, and dependence on staff for transfers, toileting, and mobility, with use of a mechanical stand lift (EZ stand). Her care plan directed staff to allow time for communication, provide a consistent environment, monitor and respond to unmet needs, and monitor mood and behaviors, including for a psychotic disorder with delusions. The facility’s abuse and vulnerable adult policy defined abuse to include verbal and mental abuse and required that suspected abuse be reported to the Office of Health Facility Complaints (OHFC) not later than two hours after forming the suspicion, with immediate steps to protect residents, including immediate suspension of staff alleged to have abused a resident. Despite this, after NA-B and NA-C witnessed and described NA-A’s loud, stern, and threatening statements to R1, they reported their concerns that evening to the on-duty LPN (LPN-A), who acknowledged the conduct as verbal abuse but did not initiate immediate reporting or protective actions as required by policy.

Instead of contacting the DON, administrator, or manager on call immediately, LPN-A told the NAs she would speak to the nurse manager (RN-A) the next day. The trained medication assistant (TMA) was also informed that evening and understood that the DON should be called within two hours so the incident could be reported to the SA, but she did not make the report herself and left it to LPN-A. NA-A remained on duty and continued working on the unit until the end of her shift, with unsupervised contact with other residents. The DON and RN-A were not notified until the following day in the early afternoon, at which time the facility submitted the vulnerable adult maltreatment report to the SA, documenting the most recent occurrence as the prior evening. Facility leadership, including the DON and administrator, later confirmed that the facility’s abuse reporting policy, including the two-hour reporting requirement for suspected abuse, was not followed and that the allegation of verbal abuse was reported late to the SA.

Title: Late Reporting of Verbal Abuse Allegation to State Agency

ShortSummary: A resident with severe cognitive impairment, dementia, depression, anxiety, and a psychotic disorder was observed crying and distraught during evening cares while an NA used a loud, stern, and verbally aggressive tone, including calling the resident a crybaby, comparing her to a two-year-old, threatening to hit her back if struck, and referencing placement in a locked unit. Two NAs and a TMA recognized the conduct as inappropriate and reported it that evening to an LPN, who acknowledged it as verbal abuse but did not immediately notify the DON, administrator, or manager on call as required by facility policy. The NA alleged to have committed the verbal abuse remained on duty with continued resident contact until the end of the shift, and the DON and nurse manager were not informed until the following day, when the incident was finally reported to the State Agency, outside the required two-hour reporting window.