F0609

D

Failure to Report and Investigate Alleged Abuse and Suspicious Injuries

Dallas, Texas Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that an allegation of abuse involving a resident was reported and investigated in accordance with state and federal requirements. The resident was an elderly male with metabolic encephalopathy, vascular dementia, diabetes, insomnia, and severe cognitive impairment (BIMS score of 6), who required moderate assistance with ADLs, used a walker, and was frequently incontinent. He was receiving multiple psychotropic and high‑risk medications, including Seroquel, Depakote, Trazodone, Remeron, and later PRN Xanax and Haldol for agitation and behavioral issues. Nursing notes documented escalating outbursts and aggressive behavior on multiple dates, including yelling, kicking, hitting, scratching staff, and knocking down tables and chairs, with new PRN psychotropic orders obtained. A late entry note on 12/30/25 documented a scratch to the right side of the resident’s face.

Staff interviews revealed conflicting accounts of the behavioral incident(s) and the resident’s injuries. One CNA reported that on the morning of 12/24/25 the resident resisted ADL care, was taken to the dining room, began knocking on the table and making noise, and was then removed to his room; she stated she did not observe bruises or injuries afterward. Another CNA (CNA D) reported that around 12/30/25 a staff member contacted her, expressing fear about reporting what occurred and believing staff on the secured unit had been aggressive with the resident and harmed him. CNA D stated she had photos showing scratches and reddened areas on the resident’s face, forearm, and hand, and that she showed these photos to the ADON. She reported that the ADON told her she already knew about the incident, stated the resident had struck the nurse’s nose, and instructed her to show the photos to the same nurse (LVN A) so the nurse could document any injuries. CNA D believed no formal abuse or injury‑of‑unknown‑source investigation was initiated, that the incident was not reported to the state, and that alleged involved staff were not removed from the resident’s care.

Additional interviews further demonstrated that an allegation of possible abuse and suspicious injuries was not treated as a reportable incident. LVN A acknowledged a behavioral episode in the dining room, stated the resident hit her nose, and later described the resident as wild and flailing, asserting that a facial scratch was self‑inflicted. The ADON stated she was present shortly after the behavioral escalation, saw the resident in his room, and later viewed photos on a CNA’s phone showing redness/scratches, but she did not believe the photos indicated abuse and did not initiate an internal abuse investigation, concluding any markings were related to the behavioral episode and redirection. The DON and corporate nurse reported they became aware of concerns only when state surveyors arrived, did not personally see the photos, and did not identify injuries on subsequent assessments; they stated the situation did not meet criteria for mandatory reporting to HHSC and no staff were suspended. Another CNA (CNA E) described hearing loud commotion, observing staff using loud, commanding voices, and later seeing blood running down the resident’s face, swelling around the eye, and bruising to the wrist and hand; she expressed fear of retaliation and concern that internal reporting mechanisms were not safe. Despite these staff concerns, photographic evidence of injuries, and the state’s definition requiring reporting of suspected abuse and suspicious injuries of unknown source, the facility did not immediately report the allegation or initiate a formal abuse or injury‑of‑unknown‑source investigation as required.