F0600

J

Resident dragged by CNA while staff fail to intervene to prevent abuse

Weatherford, Texas Survey Completed on 01-12-2026

Penalty

Fine: $34,394

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse and neglect when a CNA dragged the resident by her ankles down a hallway after the resident refused incontinent care. The resident was an elderly female on the memory care unit with vascular dementia, severe cognitive impairment (BIMS score of 4), anxiety disorder, peripheral vascular disease, osteoarthritis of both knees, and lipodermatosclerosis. Her admission MDS documented bowel and bladder incontinence, wandering, inattention, and disorganized thinking, and indicated she did not resist care or display behavioral symptoms or aggression toward others. Her care plan included mixed bladder incontinence with checks every two hours and an ADL self-performance deficit requiring assistance of one staff for toileting and total assistance with transfers, but it did not specify the number of CNAs required for transfers. The care plan was later updated after the incident to reflect resistance to care and potential physical aggression, and to include approaches such as allowing the resident to make decisions, giving clear explanations, and leaving and returning if she resisted ADLs.

On the morning of the incident, CNA A was the only CNA assigned to the memory care unit on the 6:00 a.m. to 2:00 p.m. shift. According to LVN D, around 6:00 a.m. CNA A reported that the resident was “acting up,” was dirty, and refused to be changed. When LVN D went to the unit, she observed the resident sitting in a chair, smelling of feces, while CNA A stood in front of her talking loudly. LVN D stated that CNA A attempted to get the resident up, the resident refused and continued to yell, and CNA A then reached under the resident’s arms to pick her up. The resident grabbed the chair to resist and slid to the floor. LVN D reported that CNA A then grabbed the resident’s ankles and dragged her on the floor down the hall to her room while the resident screamed, yelled, and resisted. LVN D did not intervene, stating she was shocked and afraid that intervening would aggravate the situation because CNA A was very agitated and physically large.

CNA B reported that shortly after 5:00 a.m. she asked CNA A for assistance, and that when CNA A entered the unit she began screaming at the resident to get up and gave her a countdown to three. CNA B stated the resident was sitting in a gray chair by the television when CNA A grabbed her, picked her up out of the chair, lowered her to the floor, then grabbed her by the ankles and dragged her from the lobby chair to her room. CNA B stated that she and CNA C only intervened once they reached the room, as directed by LVN D, and that she did not immediately intervene or report the incident herself because she believed LVN D had notified the abuse coordinator/administrator. CNA A, in her interview, claimed the resident threw herself out of the chair, kicked at her, and wrapped her arms around CNA A’s legs, and that she pulled the resident by the legs to her room out of concern for the safety of other residents nearby, while LVN D, CNA B, and CNA C did not assist.

Video footage of the event, later reviewed by the administrator, police, and surveyors, showed the resident sitting in a chair in the memory care lobby with six other residents visible. LVN D stood behind the resident and did not intervene while CNA A stood over the resident, pointing and shaking her finger in the resident’s face. The video showed the resident looking up at CNA A and not resisting or striking out. CNA A then grabbed the resident under the arms, jerked her up while the resident held onto the chair arms, causing the resident to fall to the floor. CNA A immediately grabbed the resident’s right leg, then both ankles, and dragged her on her back down the hallway to her room and halfway inside the doorway before the video ended. Throughout the incident, CNA A, CNA B, CNA C, and LVN D were observed standing calmly, and no one intervened to protect the resident. The facility’s abuse, neglect, and misappropriation prevention policy stated that residents have the right to be free from abuse and neglect, including physical abuse and corporal punishment, and emphasized protecting residents from abuse by anyone and maintaining a culture of compassion and caring, particularly for residents with behavioral, cognitive, or emotional problems. The surveyors determined that the facility failed to ensure residents were free from abuse and neglect, resulting in an Immediate Jeopardy situation that began on the date of the incident and was later abated.

Removal Plan

• Conduct a skin assessment for Resident #1 to confirm no open areas or bruising.
• Notify the responsible party, Ombudsman, and Medical Director.
• Notify police.
• Reassign the involved CNA away from resident care pending investigation.
• Suspend the involved CNA pending investigation.
• Conduct skin assessments for all residents in the secured unit.
• Administer a safety survey to interviewable residents in the secured unit.
• Conduct skin assessments for residents unable to answer safety survey questions.
• Provide education to designated educators (managers) on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity.
• Administer a competency test to designated educators (managers).
• Provide education to all staff on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity.
• Administer a competency test to all staff.
• Conduct weekly interviews of five staff and five residents for four weeks to ensure allegations of abuse are reported.
• Immediately address and report any concerns identified during interviews to the administrator.
• Have Department Heads or designee conduct the interviews.
• Review progress notes and incident reports during morning clinical meetings to ensure any documented abuse or potential abuse is reported to the administrator/abuse coordinator and to HHSC per regulation.
• Have the weekend supervisor review progress notes and incident reports to ensure any documented abuse or potential abuse is reported to the administrator/abuse coordinator and to HHSC per regulation.
• Hold an ad hoc QAPI meeting with the Medical Director regarding the alleged incident and the facility's plan for compliance with regulations.