F0600

J

Resident Dragged on Blanket and Verbally Abused by Night Staff

Ralls, Texas Survey Completed on 01-14-2026

Penalty

Fine: $25,480

Summary

The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse and to ensure a safe environment free from abuse. The resident was an elderly female with Alzheimer’s disease, schizoaffective disorder (bipolar type), paranoid schizophrenia, generalized anxiety, intermittent explosive disorder, insomnia, conversion disorder with seizures/convulsions, muscle weakness, and difficulty walking. Her MDS showed a BIMS score of 6, indicating severe cognitive impairment, daily rejection of care, and psychosis with hallucinations and delusions. She used a wheelchair and had care plan focuses addressing aggressive behaviors, delirium risk, and mood problems, with interventions including simple communication, monitoring for agitation, and medication management.

On the evening of the incident, video footage showed the resident sitting alone in the dining room in her wheelchair, reading a book or Bible and watching TV. LVN A and CNA B engaged in a verbal exchange with the resident after she told them to stop talking about someone; staff told her to “mind your business” and made repeated comments about finding another place for her to live and questioning why she had not been made to move. LVN A stated she was going to find a new place for the resident and that the resident could not stay there, and made a gesture with her hand across her neck while making a sound with her mouth. CNA B then repeatedly told the resident she needed to go to bed, turned off the dining room and TV room lights while the resident was reading and watching TV, and stood on a chair to turn off ceiling fan lights, despite the resident stating she did not want to go to bed and telling staff not to tell her what to do.

The video further showed CNA B pushing the resident in her wheelchair toward the hall while the resident resisted by pushing her feet toward the ground and telling staff to stop. As the wheelchair was pushed, the resident reached for an overbed table and went forward out of the wheelchair onto the floor. Staff then left her on the floor at LVN A’s direction before discussing using a blanket to move her. The resident was observed on the floor, verbally telling staff to stop, and striking out at staff while they continued to interact with her. CNA B obtained a blanket, and together CNA B, LVN A, and CNA C placed the blanket over the resident; CNA B grabbed the resident’s forearm and began dragging her down the hall on the blanket while the resident attempted to hit and kick. CNA C grabbed the blanket at the resident’s feet and assisted CNA B in dragging the resident down the hall and into her room, while LVN A walked alongside and made comments including that the resident should be sent out. The resident later reported to the ADON that she had been dragged down the hall on a blanket when she refused to go to bed early, and a skin assessment documented bruising to her lower forearm. None of the three staff on duty reported the incident at the time, and they continued to work subsequent shifts with the resident before the incident was discovered via video review.

Interviews with administrative staff corroborated that LVN A, CNA B, and CNA C verbally abused the resident, forced her toward her room in the wheelchair, pushed the wheelchair so hard that she came out of the chair onto the floor, and then wrapped her in a sheet or blanket and dragged her down the hall to her room while she was telling them to stop. The ADM and DON both described that the resident had been quietly reading her Bible and was not bothering anyone before staff decided she needed to go to bed, turned off the lights, and escalated the situation. The BOM’s review of the video confirmed that staff told the resident to mind her own business, threatened to get her out of the facility, turned off lights that were not normally turned off, pushed her in the wheelchair until she fell out, and then dragged her down the hall on a sheet or blanket. Staff interviews showed that LVN A believed using a blanket to move the resident was the safest option and did not consider it abuse, despite prior in-service training that dragging a resident down the hall on a blanket and turning off lights to force a resident to bed are forms of abuse. Other staff interviewed stated that residents should not be forced to go to bed, forcefully pushed in wheelchairs when refusing, or dragged on the floor to their rooms.