F0600

K

Failure to Prevent Neglect Due to Inadequate Staffing and Improper Transfers

Merkel, Texas Survey Completed on 02-16-2026

Penalty

Fine: $204,535

Summary

The deficiency involves the facility’s failure to protect multiple residents from neglect by not providing sufficient, qualified staff and by allowing untrained aides to perform transfers and incontinence care alone, contrary to the facility assessment, policies, and care plans. Timecard review showed that on 34 of 84 shifts between early January and mid-February, only one direct care staff member was on duty, despite the facility assessment requiring at least two direct care staff and one nurse per shift when residents required mechanical lifts or two-person transfers. The AIT and ADON both acknowledged ongoing staffing shortages, frequent no-shows, and that resident care suffered because the facility was short staffed. The AIT stated it was not safe to have only one aide working on the floor and that policies requiring two staff for transfers and incontinent care were not always followed.

One resident with dementia, severe cognitive impairment, and a care plan requiring two staff and a mechanical lift for transfers was dropped during a mechanical lift transfer performed by a single aide who was not certified and had no documented training or abuse/neglect education. The resident reported being dropped to the floor, then pulled back into the wheelchair and told not to report the fall; her roommate, who had moderate cognitive impairment, stated she saw the aide alone with the lift, heard the aide exclaim, and observed the resident and lift on the floor. The resident was later found dragging her leg, reported pain, and was hospitalized with a distal femur fracture requiring surgery. The aide later stated she had not been trained on mechanical lift use and denied transferring the resident alone, while another aide and a nurse gave conflicting accounts and denied assisting with the transfer.

Another resident with severe cognitive impairment and a care plan requiring two-person mechanical lift transfers was observed being transferred by a single aide using a stand-and-pivot method without a mechanical lift. The aide admitted she was the only aide working, knew the resident required a mechanical lift and two staff, and stated she routinely transferred the resident this way because no help was available. A third resident, with moderate cognitive impairment and high fall risk, required prompt response to call lights and assistance with transfers and toileting. She activated her call light to request help to the restroom, but no staff were present in the hall or at the nurses’ station; after waiting, she attempted to go alone, urinated on herself, slipped, and was found on the floor by a hospice aide while the call light was still engaged. The AIT confirmed that only one aide was on duty that shift, that staff no-shows were common, and did not explain why she and the ADON, who were in the office, did not answer call lights.

A fourth resident with moderate cognitive impairment, colon cancer, muscle weakness, and a high fall risk had multiple falls over several weeks, including two falls on the same day that resulted in rib fractures, pleural effusion, and hospitalization, and another fall causing a forehead injury. Progress notes documented repeated falls related to attempts to transfer or reach items independently, and the resident’s representative reported the resident was anxious and tried to get up on her own. The care plan for falls had not been updated with new interventions since several months prior, despite the series of falls. Timecards showed that during at least two of the resident’s falls, only one direct care staff member was on duty.

A fifth resident with severe cognitive impairment, depression, anxiety, mixed bladder incontinence, and a care plan requiring staff assistance for toileting and checks/changes every two hours was left in wet clothing for approximately two hours after requesting help. She first asked the only aide on duty, who told her she was too busy. The resident was later observed crying in the hall and then sitting in the dining room with visibly wet pants. When she asked an RN to change her, the RN looked at her but did not acknowledge the request. The resident became upset and attempted to remove her wet clothes in the dining room, after which the ADON reprimanded her and told her to go to her room. She was not assisted with changing until about two hours after her initial request. The aide later stated she was working alone, was very busy, and acknowledged that being short staffed could lead to residents not getting the care they needed and could be considered neglect.

Personnel file reviews showed that aides designated as nurse aides were not certified and lacked documented training, including mechanical lift training and, in at least one case, abuse/neglect training. The facility’s policies required two staff for mechanical lift transfers and prohibited aides from performing transfers and incontinent care alone, and the facility’s abuse and neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. The MD stated his expectation that residents be free from abuse and neglect, that policies be followed, and that residents’ needs be met by staff with the knowledge and skills to provide necessary care, and he confirmed that being dropped from a mechanical lift could cause the type of femur fracture sustained by one resident and that not following transfer policies could have led to injury for another resident. An Immediate Jeopardy situation was identified related to these failures.

Removal Plan

• Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse; if there are any mechanical lift residents, ensure a total of one LVN/RN and two direct care staff are in the building at all times; assess staffing requirements weekly based on census and resident needs; maintain two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
• Ensure DON and ADON verify that all agency or temporary direct care staff have documented training/credentials prior to working a shift (including checking the agency portal and obtaining CNA credentials from the sister facility) and ongoing.
• Assess Residents #5, #3, #2, and #16 for any further injury, pain, or emotional distress.
• Report Resident #1's fall to the state agency per reporting requirements.
• Assess and monitor Resident #1 for negative outcomes.
• Remove NA-A from resident care pending investigation.
• Complete investigation of the incident by AIT.
• Terminate NA-A as disciplinary action.
• Create an informational handout for incident reporting and mechanical lift use and review it.
• Provide an instructional mechanical lift demonstration for all staff by the facility's COTA.
• Review incidents within the last 30 days to identify other residents at risk.
• Re-educate all direct care nursing staff on shift on abuse/neglect policy (including safe transfer procedures and supervision expectations) with a signature sheet; require review for all direct care staff before start of first shift.
• Provide abuse/neglect and related education at an in-service with a signature page.
• Ensure the agency and sister facility only send CNAs.
• Require the charge nurse to verbally educate any agency and sister facility staff on call lights, mechanical lift, and abuse/neglect during shift report prior to the aide starting the shift; require verbal return instruction to determine competency.
• Re-educate all residents about their rights, abuse, neglect, and reporting.
• Review abuse, neglect, transfers, and reporting upon hire; provide monthly review at mandatory in-service; provide one-on-one education annually at staff hire anniversary; enforce that any violations of policy will result in termination.
• Require the charge nurse to initial, date, and log the name of each agency and sister facility staff member educated.
• Complete a mandatory all-staff in-service reviewing falls and fall prevention, reporting incidents, mechanical lift transfers, and abuse and neglect.
• Reinforce expectation that violations of abuse/neglect, mechanical lift, and reporting policies will result in disciplinary action up to and including immediate termination.
• Train all staff on falls and call light usage via phone calls with return instruction to ensure retention of information; prevent staff who do not answer the phone from returning to work until retrained; maintain a DON log of staff contacted and educated.
• Have DON/designee review all incidents daily for 30 days to establish a risk-of-incident analysis based on patterns of staffing and incidents.
• Conduct a monthly abuse/neglect audit for direct care staff and incidents and report to QAPI for 3 months.