F0607

J

Failure to Remove Alleged Abusive Nurse and Timely Report Abuse Allegation

Schulenburg, Texas Survey Completed on 02-20-2026

Penalty

Fine: $19,121

Summary

The deficiency involves the facility’s failure to implement its written abuse, neglect, and exploitation policies when an allegation of physical and verbal abuse was made against a nurse. A male resident in his early fifties with bipolar disorder (current hypomanic episode), thrombotic microangiopathy, and systemic lupus erythematosus, who had a care plan indicating dependence on staff for emotional, intellectual, physical, and social needs and an MDS showing moderate cognitive impairment, reported being struck on the back of the head by an LVN in the dining room. A medication technician (MT) texted the Administrator the same morning to report that the LVN had argued with the resident about going to his room, threatened that she could “show him what a nurse [is] about” once he was off parole, and that the resident said the LVN had tapped him on the back of the head. The Administrator responded that she would take care of it but did not come to the facility that day.

Multiple staff and the resident provided consistent accounts of the incident and its immediate impact. The resident stated that the LVN told him to sit right or he would fall back, get blood on the floor, and she would have to pick it up, and then hit the back of his head; he said it did not hurt but made him feel like she could take over him and made him feel stupid, and that his head went forward. A CNA in the dining room reported seeing the LVN touch the back of the resident’s head, causing his head to move forward, and confirmed with the resident that the LVN had pushed his head; she stated it was never okay to touch a resident in that manner and that the LVN did not apologize or excuse herself. Another CNA also reported seeing the LVN push the resident’s head forward and stated that staff had been trained many times on abuse and neglect and that such conduct was not acceptable. Both CNAs indicated they understood the Administrator to be the abuse and neglect coordinator and that abuse and neglect should be reported immediately.

Despite these reports, the LVN remained on duty and continued to care for the resident for the remainder of the day of the incident and the following day. The resident later told staff he was scared or uncomfortable asking the LVN for anything, including PRN and pain medications, during that weekend and that he isolated himself somewhat and felt humiliated by being hit in front of others. The ADON, who first learned of the allegation two days after the incident, assessed the resident and confirmed that he reported the LVN had pushed the back of his head and that he had felt unsafe and afraid to ask her for PRN medication over the weekend. The DON and ADON both stated that the LVN was known to be easily agitated and that, under facility policy, any staff member alleged to have committed abuse should be immediately suspended pending investigation.

The Administrator acknowledged receiving the text report of the allegation on the day it occurred and admitted she did not report the allegation to the state agency until two days later. 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 regional nurse consultant all stated that the facility’s abuse and neglect policies required immediate reporting of any allegation of abuse or neglect to the state and immediate suspension of any staff member alleged to be involved, and that these procedures were not followed. Review of the written facility policy on Abuse, Neglect and Exploitation confirmed that any employee alleged to be involved in abuse or neglect was to be interviewed and suspended pending investigation and not permitted to return to work unless allegations were unsubstantiated or residents were determined not to be in danger. The surveyors concluded that the facility failed to implement these policies for this resident when the Administrator did not promptly report the allegation or remove the LVN from duty after the alleged abuse was reported.