F0610

J

Failure to Timely Investigate Verbal Abuse Allegation and Implement Protective Measures

Byram, Mississippi Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly and thoroughly investigate an allegation of verbal abuse and to implement immediate protective measures after the allegation was reported. On 2/14/26 at approximately 8:40 AM, the resident representative (RR) for Resident #1 reported an allegation of verbal abuse to the RN Supervisor (RN #2), including an audio recording made on the resident’s cell phone that captured staff cursing at the resident while the resident was heard screaming. RN #2 notified the DON by telephone at approximately 8:50 AM, and the DON notified the Administrator at approximately 9:01 AM. Staff who heard the recording, including RN #1 and RN #2, considered the interaction abusive and were able to identify the voice of Resident #1, though they did not initially recognize the staff voices. Despite this, the Administrator and DON did not come to the facility on 2/14/26, and no formal investigation was initiated that day.

The facility’s own Abuse Policy and Procedure, dated 1/24/22, required that all alleged violations be thoroughly investigated under the direct supervision of the Administrator, that all necessary steps be taken to prevent further potential abuse while the investigation was in progress, and that any employee suspected of abuse be suspended pending investigation. The policy also required that residents be protected from harm through frequent supervision and reassurance during and after the investigation. Contrary to this policy, on 2/14/26 there were no interviews of staff or other residents, no documented resident assessments for signs or symptoms of abuse, and no protective interventions implemented beyond moving Resident #1 to another unit. The DON stated she had instructed RN #1 to follow up on 2/14/26 at approximately 10:00 AM but was not aware of any interviews or other investigative steps taken that day. RN #1 confirmed that she did not conduct any interviews, did not assess any residents, and did not place any interventions in place to protect residents on 2/14/26.

The investigation did not substantively begin until 2/15/26 and 2/16/26. The DON reported to the facility on 2/15/26 at approximately 10:00 AM and conducted a single interview with Resident #1 and attempted, unsuccessfully, to locate the recording on the resident’s cell phone; she did not contact the RR or conduct any other interviews that day. On 2/16/26, the DON contacted the RR for the first time since the initial notification, obtained the audio recording at approximately 11:16 AM, and, together with the Lead CNA Supervisor, listened to it and identified the voices of Resident #1, CNA #1, and CNA #2. The DON also determined that CNA #2 had been present during the incident and ascertained that the incident date was 2/10/26. Interviews of other residents were delegated to the Social Services Director, who reported interviewing four residents on one hall on 2/19/26. Throughout the period from 2/14/26 until 2/16/26, the facility did not immediately suspend all staff suspected of involvement, and staff alleged to be involved continued to provide resident care, despite the existence of an audio recording that facility staff and administration validated as capturing abusive language toward Resident #1.

The Administrator confirmed that he had delegated responsibility for investigating the allegation to the DON and was unaware of any staff interviews conducted prior to 2/16/26. Multiple staff, including the DON, RN #1, RN #2, and the Social Services Director, acknowledged that failure to thoroughly investigate an allegation of abuse could result in continued abuse of residents. The State Agency determined that the facility’s failure to initiate a timely investigation and implement protective measures after the allegation was reported on 2/14/26 created the likelihood of continued abuse of Resident #1 and other residents and placed them in a situation likely to cause serious harm, serious injury, serious impairment, or death. This failure resulted in Immediate Jeopardy and Substandard Quality of Care at 42 CFR 483.12(c)(2), Investigation of Alleged Violations, with an initial scope and severity level of J.