F0609

D

Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse

Cleburne, Texas Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an alleged resident-to-resident physical altercation as required by federal regulations, state law, and the facility’s own abuse, neglect, and exploitation policy. On 01/31/2026, a licensed vocational nurse (LVN A) documented that one resident with severe cognitive impairment and a history of physical aggression became agitated after another resident with severe cognitive impairment and a history of wandering entered his room. According to the progress note, the first resident followed the second resident down the hall from his wheelchair and initiated a fist fight, punching at the other resident, with a brief fight occurring until staff told them to stop. The note stated that the residents’ arms made contact, there were no signs or symptoms of injury, and no complaints of pain.

Both residents involved had significant cognitive and behavioral issues documented in their records. The first resident, a 61-year-old male with alcoholic polyneuropathy, vascular dementia, and aphasia, had an MDS score indicating severe cognitive issues and documented physical behavioral symptoms toward others occurring 1 to 3 days, as well as a care plan focus for behavioral problems including a prior incident of hitting another resident. The second resident, a 75-year-old male with dementia, bipolar disorder, and anxiety disorder, also had an MDS score indicating severe cognitive issues and continuous delirium-related inattention and disorganized thinking, and a care plan focus for behavior problems including agitation, aggression toward staff, and punching at the air when frustrated. Care plan interventions for both residents included monitoring behaviors, anticipating needs, and intervening calmly to prevent escalation.

Despite the documented altercation and the facility’s written policy requiring immediate reporting of all resident-to-resident altercations involving allegations of abuse to the Administrator and subsequent reporting by the Administrator to the state agency within specified time frames, the incident was not reported to the State Survey Agency through the TULIP portal until 02/13/2026. Review of TULIP records showed no report of the 01/31/2026 incident until that date. In interviews, LVN A stated that the residents started to hit each other but did not make contact and that he reported the incident to the Administrator, DON, and ADON. The Administrator stated he did not self-report the incident because he believed there was no physical contact and did not think it needed to be reported based on how it was explained to him, although he acknowledged that the progress note indicated an intent to hurt and potential for frightening the other resident. The DON stated the incident was a resident-to-resident physical altercation that was neither investigated nor reported to HHS, despite facility policy requiring investigation and reporting of all such allegations.