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F0607
D

Failure to Suspend Staff Following Abuse Allegation

El Paso, Texas Survey Completed on 04-24-2025

Penalty

Fine: $101,195
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of one resident who alleged that a night nurse had hit him on the chest and acted aggressively. The resident, a male with a history of pulmonary hypertension, right-sided heart failure, and episodes of syncope, reported that a male night nurse matching the description of a staff member had struck him. Multiple staff interviews confirmed that the description provided by the resident matched a specific LVN, who was working during the relevant period. Despite the facility's abuse policy requiring immediate suspension of any employee identified as an alleged perpetrator pending investigation, the LVN in question was not promptly suspended after being identified. Interviews with the DON, HR, and the Ex-Administrator revealed inconsistencies and lack of documentation regarding the LVN's suspension. HR could not find any record of a suspension, and timesheets indicated the LVN continued to work during the period in question. The Ex-Administrator and other staff acknowledged that the LVN matched the resident's description and that policy required suspension, but this was not consistently or clearly carried out. The facility's own abuse and neglect policy states that employees alleged to have committed abuse must be immediately suspended pending investigation to protect residents. However, the investigation summary and provider action taken did not reflect this requirement, and the LVN continued to work, only being removed from the specific resident's care after the investigation. Staff interviews confirmed awareness of the policy but also highlighted a failure to follow it, as the LVN was not suspended as required when first identified as the alleged perpetrator.

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