F0609

D

Failure to Report Resident-to-Resident Abuse Allegation to State Authorities

Giddings, Texas Survey Completed on 01-07-2026

Penalty

Fine: $31,765

Summary

The deficiency involves the facility’s failure to immediately report an alleged resident-to-resident abuse incident to the administrator and appropriate state authorities as required by policy and regulation. On 12/13/25, a nurse (LVN A) documented in the electronic health record that one resident (Resident #4) was allegedly kicking and punching another resident (Resident #5), who was on the ground after entering Resident #4’s room. LVN A assessed both residents and noted no injuries, completed a facility incident report, and entered a progress note in Resident #4’s record, but did not notify the Administrator, DON, or abuse coordinator of the allegation. The incident was therefore not reported to Health and Human Services as an allegation of abuse.

Resident #4 was a 70-year-old man with dementia, schizophrenia, and Parkinson’s disease, with a BIMS score of 7 indicating severe cognitive impairment. His care plan included a focus on inappropriate behaviors and physical aggression, noting that on 12/13/25 he allegedly kicked and punched another resident who had entered his room. Resident #5 was a male resident with altered mental status, acute kidney failure, and thrombocytopenia, with a BIMS score of 0 indicating severe cognitive issues, and a care plan focus on residing in a secure unit due to elopement risk, need for reduced stimuli, and wandering. The alleged altercation occurred when Resident #5 wandered into Resident #4’s room, and Resident #4 became upset.

Multiple staff interviews confirmed that the incident met the facility’s definition of a reportable resident-to-resident altercation and that all staff had been trained to report abuse, neglect, and exploitation immediately to the Administrator, who served as the abuse and neglect coordinator. LVN A acknowledged he did not inform the Administrator and stated he should have done so. The DON and social worker both stated that the incident should have been reported to the State as an allegation of abuse, and the Interim Administrator stated that leadership was not made aware of the incident and therefore no investigation or state report was initiated. Review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention, Reporting, and Investigation Policy, dated 01/2026, showed a requirement to immediately protect residents, initiate investigations, and report all alleged or suspected incidents as required by Texas HHSC and CMS, which was not followed in this case.