F0600

J

Failure to Protect a Resident From Abuse and to Act on an Abuse Allegation

Schulenburg, Texas Survey Completed on 02-20-2026

Penalty

Fine: $19,121

Summary

The deficiency involves the facility’s failure to protect a resident from abuse and to implement its abuse and neglect policies after an allegation was reported. A 51-year-old male resident with bipolar disorder (current hypomanic episode), thrombotic microangiopathy, and systemic lupus erythematosus had a quarterly MDS indicating moderate cognitive issues and a care plan stating he was dependent on staff for emotional, intellectual, physical, and social needs. On the morning in question, during breakfast in the dining room, an LVN interacted with the resident in a manner that multiple witnesses and the resident described as inappropriate and abusive. The LVN told the resident to sit right or he would fall back, get blood all over the floor, and the LVN would have to pick it up, and then pushed or “popped” the back of his head, causing his head to move forward. The resident reported that this did not physically hurt but made him feel humiliated, stupid, and as if the LVN could “take over him.”

A medication technician (MT) present that morning reported by text to the Administrator that she would be writing a grievance about the LVN due to the incident at breakfast. In the text exchange, the MT stated that the LVN argued with the resident about going to his room and said she could not wait until he was off parole so she could show him what a nurse was about. The MT also relayed that the resident told her the LVN tapped him on the back of the head and that the LVN was angry because the resident had told her to quit talking to herself. The Administrator responded by text acknowledging the report and thanking the MT but did not come to the facility that day. The MT later stated she reported the incident between approximately 9:30 AM and 10:00 AM and that the LVN worked the remainder of her shift that day and her shift the following day.

Two CNAs who were in the dining room corroborated seeing the LVN touch or push the back of the resident’s head, causing his head to move forward. One CNA stated she asked the resident if the LVN had pushed his head and he confirmed that she had; she described the action as intentional, without apology, and stated it was never acceptable to touch a resident in that manner. The other CNA similarly reported seeing the LVN behind the resident and pushing his head forward, noting that even if it was not a full-force push, staff should not “play” with residents by pushing their heads. Both CNAs indicated they had been trained multiple times on abuse and neglect, knew the Administrator was the abuse and neglect coordinator, and understood that abuse and neglect should be reported immediately. They did not independently report the incident because they believed the MT had already reported it.

The resident later reported feeling uncomfortable and humiliated by the incident, stating that he avoided the LVN afterward and felt very uncomfortable asking her for his pain or PRN medications over the weekend because she remained his nurse. He reported feeling psychologically uncomfortable and isolating himself somewhat during that time. The ADON learned of the allegation on the following Monday, assessed the resident, and found no visible discoloration or skin injury. During that assessment, the resident confirmed that the LVN had pushed the back of his head, describing it as a “little pop,” and stated he had not felt safe asking the LVN for PRN medication over the weekend. The DON and ADON both indicated that prior staff reports described the LVN as easily agitated or argumentative.

The Administrator acknowledged receiving the allegation on the day it occurred but did not report it to the state agency until the following Monday. She stated she did not immediately report or suspend the LVN because she believed it was a personal issue between the MT and the LVN and wanted to investigate first. The ADON, RDO, and RNC all stated that, under facility policy and state guidelines, any allegation of abuse or neglect should be reported immediately to the state, and any staff member alleged to have committed abuse should be immediately suspended pending investigation. They further stated that the Administrator did not follow the facility’s abuse and neglect policies, did not notify nursing leadership when she first learned of the allegation, and allowed the LVN to continue working and to remain assigned to the resident after the allegation was made. The facility’s written abuse, neglect, and exploitation policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required immediate reporting and protective actions when allegations arose. The surveyors identified this as past noncompliance at the level of Immediate Jeopardy, beginning on the date of the incident and ending several days later.