F0600

D

Failure to Protect Cognitively Impaired Resident From Verbal Abuse and Delayed Reporting of Injury

Pasadena, Texas Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA. The resident was an older adult with severe vascular dementia, PTSD, anxiety, depression, psychotic disorder with delusions, cognitive communication deficit, ataxic gait, and a history of behavioral episodes including hitting and pushing other residents and attempting to hit staff. His BIMS score was 3/15, indicating severe cognitive impairment, and he resided on a secure unit with care plans addressing behavior management, need for a secure environment, impaired cognition, and anticoagulant-related bruising risk. On the dates in question, the resident was known to be easily provoked by verbal aggression, loud noises, and hostility, and was particularly sensitive to environmental triggers such as fireworks and gunshots, which caused agitation and exit-seeking behaviors.

According to interviews and text-message documentation, CNA A reported to CNA B that during an overnight shift on the secure unit, the resident came around the nurse’s station and tried to hit her. In response, CNA A told the resident, “Mother fucker, you better not hit me or I’m going to show you,” which constituted cursing at and threatening the resident. CNA B later confirmed in an interview and in text communication with the DON that CNA A had cussed and threatened the resident using those words. RN B described CNA A as having a loud and assertive personality that the resident did not like, and stated that the resident was extremely agitated and exit-seeking during the New Year’s Eve period due to fireworks and gunshots in the neighborhood. The facility’s behavior management and combative resident policies emphasized de-escalation, redirection, and therapeutic techniques, but there is no indication in the report that such approaches were used by CNA A during this encounter; instead, the interaction involved verbal aggression toward the resident.

In addition to the verbal abuse, the report documents that bruising was later observed on the resident’s right hand and forearm. RN A first noted the bruising early in the morning during rounds, describing purple discoloration from the top of the hand to the wrist, a white area, and then purple discoloration on the forearm, with no open areas, edema, or reported pain. The resident was unable to explain how the bruising occurred. CNA B stated she had noticed bruising on the resident’s right forearm while providing care on a prior shift but assumed it was old and did not report it to a nurse at that time. The DON and ADM stated that CNA B had observed the bruising and failed to report it, and that CNA B also did not immediately report the allegation that CNA A had cussed at and threatened the resident. The physician, family, and staff interviews acknowledged the resident’s PTSD, sensitivity to loud noises and dominance, and tendency to lash out or swing his arms protectively when feeling threatened, but the cause of the bruising was not determined within the report. The deficiency centers on the facility’s failure to ensure the resident was free from verbal abuse by staff and the associated failure of timely reporting by staff who became aware of the abusive statement and the bruising.

The facility’s own policies on behavior management and care of combative residents required comprehensive assessment, recognition of behavioral triggers, use of non-pharmacological interventions such as redirection and de-escalation, and prompt reporting of changes in behavior or condition to licensed staff and appropriate parties. Despite these policies and ongoing in-service training on abuse, neglect, and exploitation, the documented events show that a CNA used profane and threatening language toward a cognitively impaired, behaviorally vulnerable resident, and another CNA delayed reporting both the verbal abuse and the observed bruising. These actions and inactions directly led to the cited deficiency for failure to ensure the resident was free from abuse.

The report also notes that the resident’s care plan included specific behavioral incidents over time, such as cursing, yelling, hitting other residents, and attempting to hit staff, with interventions including psychiatric evaluation, separation from other residents, attempts to move him to quieter areas, distraction, and behavior control techniques like redirection and calming. Staff interviews, including those of the DON, RNs, and the physician, consistently described the resident as highly sensitive to loud noises and perceived threats, with fireworks and gunshots on New Year’s Eve exacerbating his agitation and exit-seeking. Nonetheless, during the incident in question, the CNA’s response to the resident’s approach and attempted strike was not consistent with the resident’s identified needs or the facility’s policies, resulting in the resident being subjected to verbal abuse.

Overall, the deficiency is based on the facility’s failure to ensure that the resident was free from verbal abuse by staff and the failure of staff to promptly report both the abusive interaction and the subsequent bruising observed on the resident’s wrist and forearm. These failures occurred in the context of a resident with severe cognitive impairment, PTSD, and a documented history of behavioral issues, whose care plan and diagnoses required careful, non-threatening behavioral management and adherence to abuse-prevention and reporting requirements.