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F0600
J

Resident Dragged by LVN After Fall Constitutes Abuse

Alvarado, Texas Survey Completed on 06-10-2025

Penalty

Fine: $15,940
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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 resident with severe cognitive impairment, Alzheimer's disease, chronic kidney disease, muscle wasting, and lack of coordination experienced an unwitnessed fall in his room. The resident was found on the floor, unclothed, with evidence of bowel movement on himself, the bed, chair, and floor. The resident required partial to moderate assistance with activities of daily living and was care planned for impaired cognitive function, with specific interventions for communication and agitation. Following the fall, video surveillance and written statements from staff revealed that an LVN forcefully grabbed the resident by the wrist and dragged him across the room toward his bed, while two CNAs assisted by holding his other arm. During this improper transfer, the resident was heard expressing pain and distress, saying "oh my arm" and "please don't." The LVN did not respond to the CNAs' concerns about the resident's injuries, and the transfer was not performed according to proper procedures for assisting a resident after a fall. Interviews with the DON and ADM confirmed that the incident was considered abuse and not in line with staff training or facility policy. The facility's abuse and neglect policy explicitly prohibits such actions and requires staff to recognize and report any suspected abuse or neglect. The incident was reported to the police, and witness statements were collected from the involved staff.

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