F0600

J

Verbal and Physical Abuse of a Resident by RN and Failure to Investigate Incident

Schertz, Texas Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by a registered nurse. The resident was an adult female with a history of diffuse traumatic brain injury, mood disorder due to a physiological condition, anxiety disorder, unsteadiness on feet, cognitive communication deficit, insomnia, conversion disorder with seizures, speech and language disorder following cerebral infarction, cerebral infarction, and left-sided hemiplegia/hemiparesis. Her discharge MDS showed moderately impaired cognition with a BIMS score of 10. Her care plan noted a history of reporting that care had not been provided when it had, claiming staff tossed her down hallways without evidence of injury, and throwing herself out of bed while stating someone else had thrown her.

On the morning of 10/4/25 at approximately 5:20 a.m., an LVN heard a CNA calling from the resident’s room, reporting that the resident was kicking and punching her and asking the LVN to witness the behaviors. The LVN documented in a nursing note that the resident was hitting and kicking the CNA, that staff assisted and changed the resident into clean clothes, and that the resident came out of her room naked with her breasts exposed after taking off her clean shirt. The LVN’s later written statement described that when the RN arrived, the resident came out of her room shirtless with her breasts exposed, and the RN shouted, in the presence of the CNA, “What is this a fucking whore house, out here for everybody to see your tits,” then wheeled the resident back to her room. Inside the room, according to the LVN’s statement, the RN pulled the resident’s shirt off aggressively and continued verbal abuse, calling the resident a “fucking whore” and stating this was a place of business, not a whore house. The RN reportedly acknowledged to the LVN and CNA that she “went a little overboard” and that she knew it was verbal abuse.

The LVN’s statement further described that after the three staff went outside briefly, they saw through a window that the resident again had her shirt off with her breasts exposed. The RN extinguished her cigarette, stated she was “done,” and went back inside, followed by the LVN. The RN then pushed the resident in her wheelchair very fast and aggressively, leaned to the resident’s ear, and called her a “fucking whore” and “slut,” adding that this was why her husband left her there because he did not want a whore. The RN then, at full force, pushed the resident into her room and released the wheelchair, causing it to roll into the room and slam into the bed, which the LVN heard as a loud thud along with the resident’s scream. The LVN reported that the RN ripped the shirt off the resident’s contracted arm, causing the resident to say, “stop that hurts you bitch,” and then aggressively and forcefully removed the sweater and put on another shirt while continuing to call the resident a slut and whore, before leaving and slamming the door. The LVN stated she checked the resident for injuries and found none but did not document this assessment. A subsequent skin assessment on 10/7/25 documented no new or unusual markings or bruises. Another CNA corroborated that the resident was combative and agitated that morning and that she saw the RN get aggressive by pushing the resident into her room, calling her a slut, and shutting the door. Another resident reported being awakened by the RN yelling and hearing the RN call someone a whore and a slut, and later being told by the RN that she had been talking to the resident because she was naked. The facility did not complete an investigation report for the 10/4/25 incident at the time it occurred, despite having a written abuse, neglect, and exploitation prevention policy requiring identification and investigation of all possible incidents of abuse and protection of residents from abuse by anyone.

Removal Plan

• Report the incident to HHSC.
• Start an in-service for all staff on abuse and neglect.
• Complete a head-to-toe assessment by nursing for Resident #1.
• Notify the responsible party of Resident #1 of the incident.
• Conduct resident safety interviews.
• Terminate RN A.
• Have Resident #1 evaluated by a mental health professional.