F0607

J

Failure to Prevent, Report, and Respond to Resident Abuse

Liberty, Texas Survey Completed on 05-09-2025

Penalty

Fine: $392,920

Summary

The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse of residents, as evidenced by an incident involving a verbally aggressive altercation between a staff member and a resident. During the incident, a staff member engaged in a loud and angry argument with a resident over cigarettes, escalating to the point where the staff member challenged the resident in a threatening manner. Witnesses reported that the staff member used a mean tone and made statements that upset the resident, causing her to cry and shake. The resident, who had a history of dementia, major depressive disorder, anxiety, and hemiplegia, was left emotionally distressed by the encounter.

The facility also failed to ensure that allegations of abuse were reported to the Abuse Coordinator immediately, as required by policy. The staff member who witnessed the incident completed a concern form but did not report the incident directly to the Abuse Coordinator, Administrator, or supervisor. The concern form was left in a mailbox and not discovered until two days later, resulting in a delay in the facility's awareness and response to the abuse allegation. The staff member expressed fear of retaliation and uncertainty about the reporting process, despite having received training on abuse and reporting requirements.

Additionally, the facility did not report the abuse allegation to the state agency within the mandated two-hour timeframe after being notified. The Administrator delayed reporting the incident while working on the investigation and could not provide a logical reason for the delay. Furthermore, the facility failed to implement immediate protective measures for the resident during the investigation, as the staff member accused of abuse continued to work several shifts before being suspended. Interviews with staff and residents confirmed these lapses in policy implementation, reporting, and resident protection.

Removal Plan

• Housekeeping Staff A Terminated.
• Housekeeping Staff B was in-serviced and educated on timely reporting by Administrator.
• Safe surveys on 10 residents completed. All residents were presented with a safe survey with no concerns.
• Notification to the Medical Director and Ombudsman occurred. Notification provided by Administrator.
• Resident #2 was assessed for psychological needs by MD and was stable. Resident #2 reassessed for psychological needs and was stable per MD.
• Monitoring for emotional distress will be performed each shift and documented in resident's electronic medical record.
• Resident assessed with PHQ9 and no depression identified.
• All department heads were re-educated on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns during ad hoc QAPI. Education Performed by: Regional Nurse.
• The administrator was in-serviced on reporting Abuse within an 2 hour period of learning of the allegation. Reviewed the latest provider letter.
• Ad Hoc QAPI performed.
• All facility staff, including nursing, therapy, dietary, housekeeping, and administration, will receive training on Abuse, Neglect, Exploitation, Timely Reporting of Abuse to the Abuse Coordinator (by calling or in person) training provided via online training portal or in person by DON or designee. The in-service included detailed instruction on recognizing signs of abuse/neglect, the importance of immediate reporting, and specific methods for doing so-either by directly notifying the Abuse Coordinator in person or via phone.
• Abuse coordinator phone number is posted around the facility.
• A post-training exam with a required 100% passing score is required. Staff unable to attend the in-service will not be permitted to work until training is completed. All staff in serviced via care feed or in person.
• The Abuse Coordinator started completing daily audits of all incident/concern reports for timely response and follow-up.
• A weekly leadership team huddle (Administrator, DON, ADON, Social Worker) was implemented to review all allegations of abuse and ensure prompt interventions.
• A retrospective review of all abuse allegations from the past 30 days was initiated, no abuse allegations reported, confirm compliance and identified any gaps. Audit will be completed by: Administrator.
• Abuse Coordinator who failed to act or report in a timely manner have been counseled and educated on policy requirements by corporate staff. Counseling included a review of F607 policy requirements: mandatory reporting timelines, how and when to escalate abuse concerns, documentation expectations, and suspension protocol when allegations arise.
• Disciplinary procedures for involved parties have been initiated per HR guidelines.
• Ongoing Monthly Abuse Training: Scheduled for the second week of each month, beginning in May for three months.
• The Administrator and DON, or designee, will review all reportable 3 times a week for 30 days, then once a week for 60 days to ensure appropriate reporting procedure was followed, and appropriate interventions were initiated.
• Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings.