F0600

J

Failure to Prevent, Report, and Investigate Verbal Abuse of a Resident

Byram, Mississippi Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s right to be free from abuse and to protect residents from verbal and mental abuse after an allegation was reported. The facility’s own Abuse Policy defined verbal abuse as the use of disparaging and derogatory language and mental abuse as including humiliation, harassment, and threats of punishment or deprivation, and stated that residents were not to be subjected to abuse by anyone, including staff. Despite this, on the evening of 2/10/26, a resident was subjected to disparaging, demeaning, and derogatory language and deliberate actions intended to intimidate the resident by two CNAs during the provision of care. The resident repeatedly requested assistance and complained of pain, but was mocked, scorned, criticized, and insulted by the CNAs, and her complaints of discomfort, pain, and rough treatment were dismissed.

The resident involved had been admitted with diagnoses including encounter for other orthopedic aftercare, fracture of the right femur, and dementia, and had a BIMS score of 11 indicating moderate cognitive impairment. The resident required a wheelchair for mobility, partial/moderate assistance for dressing and bed mobility, and one-person assistance for stand-pivot transfers with weight bearing as tolerated and caution due to right hip surgery. The resident’s care plan directed staff to provide assistance as needed for ADLs and transfers, and to anticipate and meet needs based on physical or non-verbal indicators of discomfort or distress. On the evening of 2/10/26, CNA #1 was assigned to the resident’s room and, along with CNA #2, provided care during which the abusive interaction occurred. Two other CNAs were present for part of the interaction, heard CNA #1 telling the resident to get up and that she was not handicapped, saw the resident attempt unsuccessfully to stand, and then left the room without reporting what they had heard.

On 2/14/26 at approximately 8:40 AM, the resident’s representative reported an allegation of verbal abuse, supported by an audio recording, to the RN Supervisor. RN #1 and RN #2 listened to the recording with the resident and representative and described it as demeaning, degrading, cruel, and shocking, with the resident heard crying, screaming, complaining of pain and rough treatment, and begging the CNAs to stop while the CNAs mocked and laughed at her. RN #2 notified the DON at approximately 8:50 AM, and the DON notified the Administrator at approximately 9:01 AM. However, no interviews were conducted on 2/14/26, and the DON and Administrator did not come to the facility that day. The facility did not report the allegation to the State Agency within the required two-hour timeframe and did not begin a formal investigation until 2/15/26. During the investigation, the Lead CNA Supervisor and DON listened to the recording, recognized the voices of the resident and the two CNAs, and confirmed that the language and tone used were abusive, derogatory, demeaning, and malicious. CNA #2 later confirmed being present in the room throughout the incident and acknowledged being "guilty by association" for not reporting the abuse. The facility’s failure to immediately report, protect, and investigate after the allegation was made led to a finding of Immediate Jeopardy and Substandard Quality of Care under F600.

The State Agency determined that Immediate Jeopardy began on 2/14/26 when the facility failed to protect residents from abuse, failed to report the alleged abuse timely, failed to promptly investigate the allegations, and administration failed to implement and enforce the facility’s abuse policies. The facility’s failure to report, protect, and investigate abuse placed all residents at risk in a situation likely to cause serious injury, serious harm, serious impairment, or death. The abusive conduct toward the resident, combined with the delayed response and lack of immediate protective measures after the allegation was reported, constituted the core deficiency identified by surveyors.