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F0600
H

Failure to Prevent Verbal Abuse by Director of Nursing

Houston, Texas Survey Completed on 05-22-2025

Penalty

Fine: $69,455
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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 protect two residents from verbal abuse by the Director of Nursing (DON). In one incident, the DON told a male resident with severe cognitive impairment and multiple psychiatric diagnoses that she would send him to jail if he did not "shut up." Multiple staff members, including a CNA and LVN, confirmed that the DON was verbally abusive to this resident and others, frequently using threats and rude language. The resident's care plan indicated he had a history of verbal outbursts and required redirection and a calm environment, but instead, he was subjected to threatening and confrontational behavior by the DON. In a separate incident, the DON confronted a female resident with severe cognitive impairment, schizoaffective disorder, and dementia, who was agitated and yelling at the nurse's station. The DON approached the resident, got in her face, and yelled at her to "shut up" in a harsh and belittling manner. Several staff members witnessed the DON's confrontational behavior, and it was reported that the resident appeared shocked by the interaction. The resident's care plan included interventions for behavioral outbursts and required staff to redirect her calmly, but these were not followed during the incident. Interviews with multiple staff members and review of facility records revealed a pattern of unprofessional and abusive conduct by the DON toward residents and staff. The facility's abuse policy prohibits verbal abuse and requires staff to maintain professionalism and dignity in all interactions with residents. Despite these policies, the DON's actions were found to be verbally abusive and in violation of the facility's standards, as confirmed by staff interviews and documentation.

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