F0600

D

Failure to Protect Cognitively Impaired Resident From Physical and Verbal Abuse by CNA

Garland, Texas Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse by a CNA. The resident was an elderly male with Alzheimer’s disease, major depressive disorder, adjustment disorder, repeated falls, gait and mobility abnormalities, difficulty walking, and a cognitive communication deficit. His MDS showed he was severely cognitively impaired, rarely or never made himself understood or understood others, and had both short- and long-term memory problems. He was dependent for toileting and shower hygiene and required substantial assistance with dressing. His care plan identified multiple dementia-related behaviors, including urinating in inappropriate places, pushing on exit doors, removing clothing after being dressed, sitting on the floor as a refusal mechanism, and resisting care such as showering. The care plan interventions directed staff to approach him calmly, use his name, speak slowly, maintain eye contact, talk while providing care, allow time for responses, and not rush.

Despite these identified needs and interventions, a video provided by the resident’s family member showed that a CNA entered the resident’s room while he was lying on the floor next to his bed on his left side and addressed him in a scolding manner. The CNA asked, “Why you do this again, huh?” and told him to “Get up,” then slapped him on his right buttock with her hand. She repeated the question, “why you did this,” and slapped his right buttock again. The resident responded, “Oh shit, lady,” and the CNA continued to question him, telling him, “Come on. No, you are not supposed to do this, come on, sit up. Come on.” When the resident said, “I can’t,” the CNA insisted, “Yes, you can. Why you come on the floor in the first place?” The resident again said, “Oh shit,” and the CNA challenged his language, saying, “Oh shit, why you say oh shit? Give me your hand. So, this place is better than a bed?” When the resident answered, “Yes ma’am,” the CNA replied, “It’s not. Get up. Come on,” took his hand, then walked out of view as the video ended. This conduct, including slapping the resident’s buttocks and verbally chastising him, conflicted with the facility’s own abuse policy, which defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and specifically listed hitting and slapping as physical abuse.

The family member reported that the video was recorded on a prior date and stated she had sent multiple videos to facility leadership. She indicated she texted five videos to the Administrator’s personal phone number and had previously sent texts and videos to the Administrator and former ADON, but typically did not receive replies and did not speak to them personally about the video. The Administrator stated she had not seen any such video at the time, reported that the CNA stopped working at the facility not long after starting, and acknowledged that hitting a resident would not be acceptable and that the incident in the video should not have happened. The DON and other staff interviewed described abuse and neglect and agreed that hitting a resident on the bottom would not be alright and that it was never acceptable to hit a resident. The facility’s written policy on abuse, neglect, and exploitation, dated 10/24/22, stated that the facility would make every effort to prevent and prohibit all types of abuse, including physical abuse such as hitting and slapping. Nonetheless, the observed video evidence showed the CNA slapping the resident and speaking to him in a manner inconsistent with his care plan interventions and the facility’s abuse prevention policy, resulting in a cited failure to ensure the resident’s right to be free from abuse.