F0600

G

Verbal Abuse and Rough Handling of Cognitively Impaired Resident During Care

Maryville, Missouri Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from mental and physical abuse during the provision of care. The resident had dementia, chronic kidney disease, anemia, diabetes, anxiety disorder, chronic back pain that could worsen with movement, and a history of recent hospitalization for altered mental status. The resident’s care plan directed staff to approach slowly and calmly with clear instructions, to give space and perform cares later if the resident became overwhelmed or upset, to use gentle reassurance, reduce noise and distractions, and to keep the resident’s routine consistent. The care plan also instructed staff to monitor for nonverbal signs of pain and for acute changes from baseline dementia behaviors.

On the day of the incident, the resident was observed in a common area attempting to disrobe and refusing medications. RN A and another nurse placed the resident in a wheelchair and transported the resident to the room, where RN A, a CNA, and a CMT were involved in toileting and dressing. Witness accounts and the facility’s investigation documented that the resident was yelling, crying, and repeatedly attempting to remove clothing while staff were providing care in the bathroom. During this time, RN A used a raised, harsh, or firm tone, grabbed the resident’s forearm while telling the resident to stop and “knock it off,” and made demeaning statements, including calling or referring to the resident as a baby in response to crying and biting behavior. RN A also verbally threatened to call the resident’s spouse to report that the resident was trying to be naked in front of everyone, which a witness described as causing the resident to cry more.

After toileting and dressing, the resident remained visibly upset and continued trying to disrobe. A CMT offered to stay with the resident to help calm the resident, but RN A declined and stated that the resident needed to go to the dining room so others, including management, could see the behaviors RN A had to deal with. While transporting the resident in the wheelchair, a witness reported that RN A shook or jerked the wheelchair forward and backward several times and made a comment likening the resident to a “bucking bronc,” while RN A acknowledged making a similar “ride’em cowgirl” remark during wheelchair maneuvering. The facility’s investigation, based on multiple consistent witness statements and RN A’s own statements, concluded that RN A used demeaning and humiliating language, raised and harsh tones, threats of public shaming, and physical handling inconsistent with safe and respectful standards, including jerking the wheelchair and grabbing the resident’s forearm, which caused emotional distress to the resident even though no physical injury was identified on assessment.

The facility’s abuse policy defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included mental abuse such as humiliation, harassment, threats of punishment, or deprivation. The policy required immediate removal of a resident from a harmful environment and prompt reporting of suspected abuse. In this incident, the actions attributed to RN A—demeaning language, threats to involve the resident’s spouse to shame the resident for disrobing, refusal to allow a staff member to remain with the resident to calm them, and intentional public exposure of the resident’s distressed behavior in the dining room—were determined by the facility’s investigation to constitute verbal abuse and inappropriate physical handling. These actions did not follow the resident’s individualized care plan strategies for managing behavioral symptoms and dementia-related distress and resulted in the substantiated finding of abuse.