F0610

E

Failure to Thoroughly Investigate Multiple Abuse and Neglect Allegations

Giddings, Texas Survey Completed on 01-07-2026

Penalty

Fine: $31,765

Summary

The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse and neglect for several residents. For one cognitively intact female resident with cerebral palsy, schizophrenia, and incontinence, the record shows she required maximal assistance for toileting and was always incontinent of bowel and bladder. She alleged that unknown staff at an unknown time did not perform pericare appropriately and left feces in her vaginal area. The provider investigation report documented her complaint but only referenced general staff in-services and safe surveys that predated the allegation, with no evidence of a new, allegation-specific in-service, no new safe surveys, and no documented new skin assessment during the investigation.

A second resident, a severely cognitively impaired female with Parkinson’s disease and muscle wasting, was care planned as being at risk for falls. Nursing notes documented that she was found on her knees on the floor holding onto a table, assessed with no injuries, and returned to bed, with the physician and family notified. Later, her family reported that she had fallen and was left on the floor for over an hour. The provider investigation report again referenced only general in-services and safe surveys dated prior to the allegation, with no new in-services related to the specific incident, no formal skin assessment beyond a narrative note, and no safe surveys conducted with other residents. The DON stated she was unsure how long the resident was on the floor and confirmed that no new safe surveys or formal skin assessment were completed.

A third resident, a severely cognitively impaired male with a cervical spinal cord injury and a stage 4 sacral pressure ulcer, alleged that around the time of his admission a female agency CNA placed a pillow over his face while providing care. The provider investigation report documented the allegation and referenced abuse monitoring and staff in-services, but the in-services and safe surveys cited were dated before the allegation and were not newly initiated for this event. The DON reported that she interviewed the resident but did not attempt to identify the alleged perpetrator, did not initiate new in-services or safe surveys, and acknowledged missing multiple elements in the investigation. The resident’s care plan contained no focus related to this allegation, and key assessments such as a new skin assessment, BIMS, and trauma assessment were delayed several days after the allegation, rather than completed on the day it was reported.

The facility also failed to investigate an alleged resident-to-resident abuse incident involving two severely cognitively impaired male residents. One resident, with dementia, schizophrenia, and Parkinson’s disease, had a care plan focus for inappropriate behaviors and physical aggression, including a note that on a specific date he allegedly kicked and punched another resident who was on the ground after entering his room. Progress notes by an LVN documented that this resident was allegedly kicking and punching the other resident, who had wandered into his room. The other resident, who resided in a secure unit due to elopement risk and wandering, had severe cognitive impairment and multiple medical diagnoses including altered mental status, acute kidney failure, and thrombocytopenia. The LVN later stated he did not notify the Administrator, who was the abuse and neglect coordinator, about the incident, and the DON confirmed the event was not reported to the state and was not investigated as an allegation of physical abuse.

Interviews with the DON and Administrator further established that the investigations for the first three residents were incomplete and did not meet facility expectations or policy requirements. The DON acknowledged that no new safe surveys were conducted for the first two residents, that no formal in-service specific to pericare or the fall allegation was provided, that no timely skin assessments were documented under the correct forms, and that she did not attempt to identify the alleged perpetrator in the pillow incident. The Administrator, who started after these events, reviewed the investigations and stated they were not thorough, noting the absence of allegation-specific in-services, skills observations, resident interviews, timely assessments, and new safe surveys. The facility’s written policy on abuse, neglect, exploitation, and misappropriation requires immediate protection of residents, initiation of investigations, reporting of all alleged or suspected incidents, and retraining following incidents or identified trends, but the documented investigations and staff interviews show that these steps were not fully carried out for the cited allegations.