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F0600
D

Failure to Protect Resident from Verbal Abuse by Staff

Liberty, Texas Survey Completed on 05-09-2025

Penalty

Fine: $392,920
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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

A deficiency occurred when a staff member (HSK A) engaged in a verbally aggressive argument with a resident over cigarettes. The resident, who had diagnoses including dementia, major depressive disorder, anxiety, and hemiplegia, was able to make herself understood but had moderate cognitive impairment. During the incident, HSK A became loud and angry, and after the resident told her to "shut up," HSK A got up from her chair and challenged the resident to make her shut up. Witnesses reported that the exchange escalated, with HSK A using a mean tone and making further aggressive remarks, which caused the resident to cry and become visibly upset. The facility's records show that the incident was not reported immediately as required by policy. The witness to the event, another staff member, placed a note under the HR door but did not notify the administrator or designated abuse coordinator right away. The incident was reported to the administrator several days later, and the staff member involved continued to work in the facility during that time. The facility's policy requires immediate reporting and intervention in cases of alleged abuse, but this protocol was not followed in this instance. Interviews with the resident and other witnesses confirmed that the staff member's behavior was verbally abusive and outside the norm for interactions between staff and residents. The resident expressed feeling sad and upset at the time of the incident, and other residents present described the staff member as disrespectful and angry. The facility's own investigation confirmed the occurrence of verbal abuse, and the failure to follow established abuse prevention and reporting policies contributed to the deficiency.

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