F0600

J

Abusive Physical Intervention by DON and Failure to Remove Accused Staff from Resident Contact

Kansas City, Missouri Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse and to follow its own abuse and CPI (Crisis Prevention Intervention) policies during a behavioral incident. A cognitively intact resident with multiple psychiatric diagnoses, including Schizoaffective Disorder, Bipolar I Disorder, PTSD, Autism Spectrum Disorder, and a history of self-harm and violent temper, became upset and engaged in self-injurious behavior using a broken plastic mirror. A Code for behavioral crisis was called, and the DON, an LPN, an RN, and other staff responded. In the resident’s room, the resident held a shard of the broken mirror, threatened to harm staff if they came closer, and attempted to cut his/her left forearm. Staff, including the DON and LPN, attempted verbal de-escalation and CPI techniques, and the resident eventually dropped the shard and sat down, repeatedly asking to be sent to the hospital.

The situation escalated again when the resident attempted to leave the room. Multiple witness statements and video footage show that the DON blocked the doorway with his/her body and told the resident he/she was not going anywhere, contrary to facility policy that staff should never attempt to confine a resident to a room during a behavioral episode and should use the least restrictive interventions. As the resident tried to get past, the DON initiated physical contact, placing hands and/or forearms on the resident’s shoulder, collarbone, and neck area while the resident backed into the hallway and against the wall. The video showed the DON extending both arms toward the resident’s neck/clavicle/shoulder area, lifting a foot to block the resident’s movement, and pushing the resident’s back against the wall while holding the resident there. Witnesses, including the LPN and AA, reported that the DON’s hands appeared to move from the shoulders up to the neck, and the AA was heard repeatedly yelling for the DON to keep hands on the resident’s shoulders.

The facility’s internal investigation, supported by witness accounts, video footage, and the resident’s own statements, determined that the DON initiated inappropriate physical contact, used unnecessary physical force, and placed a hand around the resident’s neck area during the attempted hold. This contact around the neck was not consistent with approved CPI techniques, was strictly prohibited by facility policy, and represented a misuse of authority and a violation of the resident’s dignity and rights. The investigation concluded that CPI techniques were not correctly utilized, that alternative de-escalation methods were not fully employed before physical intervention, and that the DON’s actions further stimulated and escalated the resident’s behavior. The resident reported being choked by the DON, expressed fear, nightmares, and flashbacks of the DON coming back to strangle him/her, and stated he/she did not feel safe living at the facility. Despite the incident occurring at approximately 7:40 p.m., the DON continued to work the shift until 9:45 p.m., and the employee was not immediately removed from the facility or from resident contact as required by the facility’s Abuse and Neglect Policy.

The facility’s Abuse and Neglect Policy required that employees accused of mistreatment be immediately removed from contact with residents and leave the facility pending investigation, and specifically prohibited any form of contact involving a resident’s neck. The policy also required that, if the alleged abuser was the Administrator or DON, they could remain only in non-resident areas with no resident contact. In this case, the DON remained on duty and in the facility after the incident and was not removed from resident contact during the time period described. The combination of the DON’s physical actions toward the resident, the improper and non-approved CPI techniques used, the blocking of the resident’s exit, and the failure to remove the accused staff member from resident contact constituted the abuse-related deficiency identified by surveyors.