F0600

G

Failure to Prevent Resident-to-Resident Physical Abuse and Staff Verbal Abuse

Cleburne, Texas Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from abuse and to prevent resident-to-resident altercations. One male resident with vascular dementia, severe cognitive impairment, and documented physical behaviors toward others was care planned for behavioral problems after he hit another resident. On one occasion, staff heard his roommate, an elderly male with Alzheimer’s disease and severe cognitive impairment, yelling for help and crying. When CNAs entered the shared room, they observed the aggressive resident standing over the roommate with his hand balled into a fist and pulled back, while the roommate was curled on his side with his hands over his face. Multiple staff statements and progress notes documented visible injuries to the roommate, including small open areas and scratches under the right eye and on the bridge of the nose, and the roommate repeatedly questioned why he had been hit. The aggressive resident denied hitting him but stated the roommate would not “shut up.”

Subsequent documentation showed that the same aggressive resident continued to exhibit agitation and yelling when other residents entered his room. Progress notes on several dates described him becoming agitated and yelling at other male residents who wandered into his room, requiring redirection by staff. Despite his history of physical behavior toward others and repeated episodes of agitation when other residents entered his room, he was later involved in another altercation with a different male resident with dementia and severe cognitive impairment. In that incident, the second resident wandered into his room, was asked to leave, and the aggressive resident followed him down the hall to initiate a fist fight. Staff reported that the residents began swinging at each other, arms made contact, and they stopped when told to do so. No injuries were noted, but the event was documented as a resident-to-resident altercation with physical contact.

The deficiency also includes an incident of verbal and emotional abuse toward a female resident with Alzheimer’s disease, dementia, depression, and moderate cognitive impairment. This resident had a care plan for wandering and exit seeking. On one night, a CNA reported that an LVN yelled at the resident, told her to sit in her wheelchair and not move, and blocked her from getting up while the resident repeatedly stated she needed to use the bathroom and feared she would urinate on herself. According to the CNA’s written and verbal statements, the LVN told the resident she was lying about needing the bathroom and called her “nothing but a liar,” while the resident became upset, cried, and begged to go to the bathroom. The CNA described this as verbal abuse and neglect and removed the resident from the situation. The LVN later acknowledged telling the resident she was lying about needing the bathroom, though she denied yelling or preventing her from leaving the wheelchair. Facility leadership, including the Administrator, ADON, and DON, stated that calling a resident a liar is inappropriate, abusive, and could be considered verbal or emotional abuse under the facility’s abuse, neglect, and exploitation policy, which defines physical abuse as hitting or punching and mental abuse as including humiliation and harassment.

The facility’s own policy on abuse, neglect, and exploitation, dated 09/06/2024, states that it is the policy to protect residents’ health, welfare, and rights by prohibiting and preventing abuse, neglect, exploitation, and misappropriation of resident property. The policy defines physical abuse to include hitting and punching, and mental abuse to include humiliation and harassment. In the events described, residents with significant cognitive impairments and behavioral care plans were subjected to physical aggression by another resident and to verbal humiliation by a staff nurse. These actions and inactions, as documented in staff statements, progress notes, and interviews, demonstrate that the facility failed to ensure residents’ right to be free from abuse, neglect, and exploitation as required by its own policy and regulatory standards.