F0610

J

Failure to Thoroughly Investigate and Document Alleged Abuse by LVN

Schulenburg, Texas Survey Completed on 02-20-2026

Penalty

Fine: $19,121

Summary

The deficiency involves the facility’s failure to have evidence that an allegation of abuse involving one resident and an LVN was thoroughly investigated and documented. A male resident in his early fifties with bipolar disorder (current hypomanic episode), thrombotic microangiopathy, and systemic lupus erythematosus, and with moderate cognitive impairment per MDS, alleged that an LVN tapped or pushed the back of his head in the dining room after making comments about his behavior and posture. A medication technician reported by text to the Administrator that the LVN argued with the resident about going to his room, stated she could not wait until he was off parole so she could show him what a nurse was about, and that the resident told her the LVN tapped him in the back of the head. The Administrator acknowledged receiving this report on the date of the incident.

Multiple staff and the resident provided accounts of the incident and its immediate impact. The medication technician stated she heard the LVN tell the resident she could not wait until his parole release so she could show him what a nurse was about, and that the resident reported the LVN had popped him in the back of the head. A CNA reported witnessing the LVN touch the back of the resident’s head, causing his head to move forward, and confirmed that the resident told her the LVN had pushed his head; she stated it was never acceptable 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 repeatedly trained in abuse and neglect and that such behavior was not appropriate. The resident reported that the LVN was very outspoken, told him to sit right or he would fall back and get blood on the floor that she would have to clean, and then hit the back of his head, which did not cause pain but made him feel humiliated and as though she could take over him.

The Administrator, ADON, DON, RDO, and RNC all provided information indicating that the facility’s abuse and neglect policies and procedures were not implemented as required in response to this allegation. The Administrator stated she received the report of alleged abuse on the day it occurred but did not immediately report it to the state agency, did not immediately suspend the LVN, and did not promptly involve the DON or ADON, explaining that she initially believed it was a personal issue between staff and misjudged the situation. The ADON reported she did not learn of the allegation until two days later, at which time she assessed the resident and confirmed that he reported the LVN had pushed the back of his head and that he felt uncomfortable and afraid to ask her for PRN medication over the weekend. The DON and ADON both stated that the LVN continued to work and remained the resident’s nurse after the allegation was reported to the Administrator, contrary to facility policy that staff alleged to have committed abuse should be suspended pending investigation. The RDO and RNC stated that any allegation of abuse should be reported immediately to the state agency, that staff involved should be removed from duty pending investigation, and that the Administrator did not follow facility and state guidelines. Facility policy required timely investigation of any alleged abuse, neglect, mistreatment, injuries of unknown origin, or exploitation, including gathering evidence, interviewing witnesses, reviewing records, and documenting all findings and actions, but the surveyors found the facility lacked evidence that such a thorough investigation and documentation were completed for this allegation.