F0609

D

Failure to Timely Report Alleged Verbal and Physical Abuse to State Agency

Browns Valley, Minnesota Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency within the required two-hour timeframe after the allegation was made. On 2/21/26 in the evening, a trained medication assistant (TMA-A) stood outside a resident’s closed door preparing medications and heard the resident and a nursing assistant (NA-B) yelling. TMA-A heard NA-B say in a rude and aggressive tone, “hurry up and grab the fucking bar you know how to fucking walk so walk to the bed.” After NA-A and NA-B exited the room, NA-A told TMA-A that NA-B had swatted the resident on the butt. TMA-A considered this verbal and physical abuse and reported what she heard and what NA-A told her to the charge nurse (LPN-A) during a medication count shortly after 7:00 p.m., assuming LPN-A would notify the on-call nurse.

NA-A reported that while assisting the resident in the bathroom, the resident became combative and yelled after NA-B told her to stand up. NA-B responded, “if you want to act like a child then you will be treated like one,” and with an open hand smacked the resident on the right buttock, skin-to-skin, producing a loud smack. NA-B then grabbed the resident’s walker and directed her to walk to bed. NA-A described NA-B’s tone as loud, aggressive, and accompanied by foul language, and stated the resident was whining, whimpering, and making grunting sounds as if nervous. After leaving the room, NA-A and TMA-A reported the incident to LPN-A, who provided NA-A with a complaint form. NA-A completed the form and placed it in the DON’s box, believing the incident would be handled and reported.

The resident involved had non-Alzheimer’s dementia, depression, and a psychotic disorder, with unclear speech, limited verbal and non-verbal skills, disorganized thinking, and moderately impaired cognition with long- and short-term memory loss. She was dependent on staff for personal and toileting hygiene, transfers, bathing, and lower body dressing, and was always incontinent of bladder and frequently incontinent of bowel. Despite the information provided by TMA-A and NA-A, LPN-A did not read the written complaint, did not further question staff about the incident, and did not immediately assess the resident or contact the on-call nurse. The facility’s incident report was not submitted to the State Agency until 2/22/26 at 4:22 p.m., well beyond the policy requirement to report suspected maltreatment, including abuse, to the State Agency immediately but no later than two hours after the allegation is made. During this time, NA-B continued to work the remainder of the shift and care for residents.