F0609

D

Failure to Report Alleged Drug-Related Incident to State Agency Within Required Timeframe

San Antonio, Texas Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an alleged violation involving possible neglect and exploitation to the State Survey Agency within 24 hours, as required by regulation and the facility’s own abuse prevention policy. An incident occurred in which a package containing multiple baggies of a crystal-like substance suspected to be narcotics was delivered under suspicious circumstances and came into the possession of a resident. Although the facility notified law enforcement and secured the substance, the Administrator did not report the allegation to the State Survey Agency (HHSC). The Administrator stated he relied on a provider letter for guidance and believed there was no requirement to report because there was no concern for the residents’ health or safety and no evidence that the residents had contact with or used the drugs.

Resident #1 was an adult male with legal blindness, type 2 diabetes mellitus, and schizophrenia. His care plan documented impaired visual function/blindness with interventions including assistance with ADLs as needed. His quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and he required moderate assistance with toileting and bathing, was non‑ambulatory, but able to stand unassisted. Resident #2 was an adult female with a right tibia fracture with routine healing, major depressive disorder, and edema. Her care plan identified a self‑care performance deficit with monitoring for changes in care or declines in function. Her quarterly MDS showed a BIMS score of 15, indicating she was cognitively intact, with independence in most functions except for moderate lower‑body involvement and non‑ambulatory status.

According to the facility’s investigative report and a local police incident report, a visitor came to the facility and represented himself as a family member of Resident #2 in order to drop off a package. LVN A reported that Resident #1 asked for assistance in picking up a delivered package, and RN A assisted him in retrieving it. Upon opening the package at Resident #1’s request to check for a cross, RN A observed a cross and, underneath it, several small baggies of a white or crystal‑like substance suspected to be narcotics. Law enforcement was notified and confiscated approximately 4 grams of the substance. Interviews with both residents indicated they believed they were receiving a decorative cross from a man associated with a former resident, and both denied any knowledge of or involvement with drugs.

RN A, the weekend supervisor, reported that he assisted Resident #1 with the front door when a man delivered a gift purportedly for Resident #2. The man handed the package to Resident #1, who gave the man a bag of chips in return. RN A stated that when he inspected the package for the cross, he found the suspected drugs, questioned Resident #1, and then secured the substance, notified the DON and Administrator, and contacted the police. The DON confirmed she was called in the middle of the night about a package containing a cross or rosary and a small baggie, and she instructed RN A to notify the police. She stated that packages from unknown sources were to be opened in the presence of the resident and that the staff responded as expected. The Administrator stated he was notified by RN A, confirmed that the suspected drugs were secured and turned over to police, and conducted an internal investigation, concluding there had been a mix‑up with the package and no evidence of drug use by either resident.

Despite the facility’s abuse prevention policy stating that alleged violations would be reported via phone or email to the State Licensing Agency, the Administrator acknowledged that he did not report this incident to HHSC. He explained that he relied on a provider letter for reporting guidance and did not see anything indicating that this type of incident needed to be reported, particularly because he believed there was no impact on the residents’ health or safety and no contact with the drugs. The survey findings concluded that the facility failed to ensure that all alleged violations involving abuse, neglect, or exploitation that did not involve abuse resulting in serious bodily injury were reported to the State Survey Agency within 24 hours, as required, for two residents reviewed for freedom from abuse, neglect, and exploitation.