F0609

D

Failure to Timely Report Alleged Verbal Abuse Incident

Liberty, Texas Survey Completed on 05-09-2025

Penalty

Fine: $392,920

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by regulation. Specifically, an incident occurred in which a staff member was verbally aggressive toward a resident during a dispute over cigarettes. The incident was witnessed by another staff member, who documented the event on a concern form and left it in a mailbox outside the HR door, rather than reporting it directly and immediately to the abuse coordinator or administrator as required by facility policy. The administrator did not become aware of the incident until two days later and did not report the allegation to the state agency within the mandated two-hour timeframe.

The resident involved had a history of dementia, major depressive disorder, anxiety, and hemiplegia following a stroke. The resident was able to make herself understood and had moderate cognitive impairment. During the incident, the staff member raised her voice and made threatening remarks, causing the resident to become upset, cry, and shake. The resident later reported feeling sad and upset at the time of the incident, though she and the staff member later reconciled. The staff member continued to work scheduled shifts after the incident until the administrator was notified and suspended her pending investigation.

Interviews and record reviews revealed that the staff member who witnessed the incident did not immediately report it due to fear of retaliation, despite being trained on abuse reporting. The administrator acknowledged the delay in reporting and could not provide a logical reason for not reporting the incident promptly. Other staff and residents confirmed the details of the incident and the delay in reporting. The facility's failure to follow its own abuse prevention and reporting policies resulted in a delay in protecting the resident and in notifying the appropriate authorities.

Removal Plan

• Housekeeping Staff A terminated.
• Housekeeping Staff B was in-serviced and educated on timely reporting by Administrator.
• Safe surveys on 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 assessed for psychological needs by MD and was stable. Resident 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 a 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.
• 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 three months.
• The Administrator and DON, or designee, will review all reportable three 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.