F0607

J

Failure to Implement Abuse Reporting Policies After Resident Dragged on Blanket

Ralls, Texas Survey Completed on 01-14-2026

Penalty

Fine: $25,480

Summary

The deficiency involves the facility’s failure to implement its written policies and procedures requiring that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported immediately, and no later than two hours when abuse or neglect with bodily injury is alleged. A cognitively impaired female resident with Alzheimer’s disease, paranoid schizophrenia, schizoaffective disorder (bipolar type), generalized anxiety, intermittent explosive disorder, conversion disorder with seizures, insomnia, and a history of aggressive behaviors alleged that staff verbally and physically abused her. Her MDS showed a severely impaired BIMS score of 6, daily rejection of care, and psychosis with hallucinations and delusions, and she used a wheelchair. On 12/19, during the evening/night shift, the resident reported that staff turned off the TV while she was watching a show in the dining area, told her she had to go to bed, put a blanket over her head, grabbed her feet, and dragged her down the hall to her room on the blanket. She stated she stayed in her room that night and did not report the incident the following day.

Progress notes documented by the ADON on 12/22 indicated that the resident voiced she had been dragged down the hall on a blanket when she refused to go to bed early, that staff turned off the TV and forced her, dumped her out of her wheelchair, and then dragged her down the hall. A skin assessment on 12/22 by the ADON documented bruising to the resident’s lower forearm, and the resident was not on blood thinners at the time. Interviews and timecard reviews established that LVN A, CNA B, and CNA C were the only staff on duty on the night of 12/19 when the incident occurred, and they continued to work subsequent shifts on 12/20 and 12/21 without reporting the incident to administrative staff. The DON stated the incident occurred around 7:00 PM on 12/19 and was not reported until 12/21, when it was discovered on facility video footage shortly after the same three staff started their shift. The ADM stated he had video of the incident, that LVN A, CNA B, and CNA C abused the resident, and that all three were implicated and failed to report the event.

Interviews with the ADON and BOM showed that the resident’s allegation of abuse was not immediately reported to the Administrator prior to investigation. The BOM reported that on Sunday, as she was leaving work around 6:00 PM, the ADON called and relayed that the resident had reported an allegation of abuse but that the ADON did not know if it had occurred or which staff were involved. The BOM then reviewed the video, identified the incident and the involved staff, and notified the ADM, ADON, and corporate nurse. The ADON later acknowledged that, based on policy, she expected staff to report any abuse immediately and that staff did not follow the abuse, neglect, and exploitation policy when they failed to report the abuse the night it happened. Statements typed by administration for LVN A, CNA B, and CNA C documented that they admitted to dragging the resident down the hall on a blanket and did not believe they had done anything wrong, citing the resident’s behaviors and medication noncompliance. Despite existing policies and prior in-service training on abuse, neglect, resident rights, and the requirement to report abuse, the incident was not reported within the required timeframe, and the facility failed to ensure that its abuse/neglect reporting policies were implemented for this resident.

The facility’s written Abuse, Neglect, Exploitation, Misappropriation Prevention Program policy, revised April 2021, stated that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that the program includes identifying and investigating all possible incidents of abuse, neglect, mistreatment, or misappropriation and reporting any allegations within required federal timeframes. Interviews with multiple staff (including CNAs, LVNs, and the ADON) confirmed they had received training on abuse and neglect, reporting abuse, and resident rights, including explicit instruction that dragging a resident down the hall on a blanket and turning off lights or TV to force a resident to go to bed are forms of abuse and violations of resident rights. Nonetheless, on the night of the incident, LVN A, CNA B, and CNA C did not report the event, and the ADON and BOM did not immediately report the resident’s allegation to the Administrator before initiating review of the video. This sequence of actions and inactions led to the identified deficiency that the facility failed to implement its abuse/neglect reporting policies and procedures for this resident.

Removal Plan

• Conduct safe surveys.
• Provide in-service training on abuse and neglect, resident rights, and misappropriation.
• Review in QAPI and discuss with staff.
• Monitor camera footage across shifts to monitor staff.