F0609

D

Failure to Timely Report Resident-to-Resident Physical Abuse Allegation

Palestine, Texas Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report an alleged resident-to-resident physical abuse incident to the appropriate authorities as required. On the date in question at approximately 3:38 p.m., an LVN (LVN A) heard someone call out for the nurse, exited a resident’s room, and observed one resident (Resident #2) make contact with another resident (Resident #1) on the cheek with what appeared to be a closed fist. LVN A separated the residents, notified the DON, NP, and responsible party, and completed a skin assessment on Resident #1, which revealed no injuries or alterations in skin integrity. The incident was documented as physical aggression on an incident report.

Resident #1 was a male with autistic disorder, muscle wasting and atrophy, diabetes mellitus, and severe intellectual disability. A recent MDS indicated he was rarely or never understood, and he required varying levels of assistance with toileting hygiene, dressing, personal hygiene, eating, oral hygiene, and footwear. His care plan, dated 2/4/26, documented behavioral symptoms related to severe intellectual disability, including self-biting and yelling out when agitated, with interventions such as maintaining a calm environment, using calming techniques and words, and removing him from the area if his behavior interfered with others. Following the incident, Resident #1 was assessed as nonverbal and not appearing emotionally distressed, and later observation showed him clean, well groomed, and without suspicious marks, skin tears, or bruising.

Resident #2 was a male with unspecified dementia and a psychotic disorder with delusions due to a known physiological condition. His admission MDS showed severely impaired cognition with a BIMS score of 4 and indicated he required supervision or assistance with eating, oral hygiene, dressing, personal hygiene, toileting hygiene, showering/bathing, and footwear, with no documented physical or behavioral symptoms directed toward others. His care plan, dated 2/4/26, identified risk for impaired social interactions related to mood and psychotic disorders, with interventions including administering medications as ordered and monitoring for side effects and effectiveness. The DON and ADM acknowledged being notified of the altercation and stated they determined it was not reportable to the state because, in their view, Resident #2’s limited cognition meant he could not willfully act. This decision was made despite facility policies stating that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the administrator and other officials according to state law and HHSC reporting guidelines, and despite staff training on abuse and reporting requirements.