F0600

J

Failure to Protect Resident From Repeated Resident‑to‑Resident Physical Abuse

Mcallen, Texas Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse and to implement adequate protective interventions after a reported resident‑to‑resident physical altercation. One male resident with dementia, severe cognitive impairment (BIMS score 04), generalized anxiety disorder, major depressive disorder, and a history of verbal aggression toward staff and other residents was sharing a room with another male resident with Alzheimer’s disease and moderate cognitive impairment (BIMS score 11). The cognitively impaired aggressive resident had documented episodes of verbal aggression toward staff and residents in the months prior to the incidents, including multiple resident‑to‑resident verbal aggression events. The roommate had a history of some anger issues at home per family, but non‑physical.

On the morning of 02/07/26, staff reported a resident‑to‑resident altercation at the doorway of the shared room. CNA A stated she saw the aggressive resident holding the roommate’s shirt and striking him with a closed fist once to the jaw and once to the chest while the roommate was in his wheelchair trying to exit the room. CNA A reported this to LVN B, including her concern that the two residents could not safely remain together and that the aggressive resident could attack or even kill the roommate. LVN B assessed the roommate, documented that he denied being hit and had no injuries or emotional distress, and documented that the aggressive resident did not recall the incident and had no injuries. The DON and Administrator were notified, but no abuse investigation was initiated because the roommate denied being hit, and the facility relied on his denial despite CNA A’s eyewitness account. The facility did not separate the residents or change rooms; instead, they intermittently monitored and alternated the residents’ presence in the room, with only brief or inconsistent staff presence outside the door and no formal, continuous monitoring documentation during the night shift.

In the early morning hours of 02/08/26, a second, more serious altercation occurred between the same two residents. At approximately 4:00 a.m., staff responded to calls for help and found the roommate on the floor with the aggressive resident standing nearby; another CNA reported seeing the aggressive resident holding a bedside table at his waist and later heard him say he would hit the roommate again. Nursing staff assessments documented skin tears to both antecubital areas and the right knee, as well as redness on the bridge of the nose. The roommate stated that the aggressive resident had grabbed him by the arms and pushed him to the floor, and another nurse documented that the roommate reported being pulled from his wheelchair to the floor. Both residents were sent to the hospital for evaluation. The facility’s DON later acknowledged that, in response to the first incident, they had only implemented limited monitoring as reflected in the chart, did not conduct an abuse investigation because the roommate denied being hit, did not perform a room change, and that the second incident could have been prevented had monitoring and protective measures been continued and fully implemented. The surveyors determined that the facility failed to ensure residents were free from abuse and failed to protect the roommate after the initial reported physical altercation, resulting in a second incident with documented injuries and constituting past noncompliance at the Immediate Jeopardy level from 02/07/26 to 02/08/26.

The noncompliance was identified as past noncompliance with Immediate Jeopardy beginning on 02/07/26 and ending on 02/08/26. The facility’s failure to protect residents from abuse and to follow its abuse policy for protection during an investigation could place residents at risk of physical harm, mental anguish, and emotional distress. The DON stated that not implementing the abuse policy for protection of residents could negatively impact residents because it could cause injury, and in this case, the only negative impact identified for the roommate was superficial skin tears. The Administrator and DON both confirmed that, at the time of the first incident, they did not identify the event as abuse due to the roommate’s denial of being hit, did not initiate a formal abuse investigation, and relied on limited monitoring rather than separation or one‑to‑one supervision, which did not prevent the second altercation and resulting injuries.

Removal Plan

• Changed Resident #1’s room
• Implemented 15-minute observation checks for Resident #1
• Sent Resident #1 out of the facility
• Implemented a resident-to-resident behavior monitoring tool to identify residents with incidents/behaviors and document corrective actions taken
• Held an ADHOC QAPI meeting addressing the resident-to-resident incident
• Updated Resident #1 care plan to address resident-to-resident aggression
• Updated Resident #2 care plan to address resident-to-resident altercations
• Reviewed care plans for additional identified residents with behaviors to ensure behaviors and interventions were addressed
• Coordinated psychiatric nurse practitioner involvement via email communications identifying residents with behaviors and follow-up
• Ensured psychiatry evaluations occurred for residents with behaviors
• Conducted facility-wide in-service training for all team members on immediate reporting of abuse/injury/neglect/exploitation to the Administrator, reporting resident-to-resident aggression/inappropriate touching, redirecting and keeping residents safe, and placing residents on one-to-one monitoring and keeping them separated
• Provided additional staff training and awareness on immediately reporting abuse to the Administrator and separating residents and implementing one-to-one monitoring after resident-to-resident altercations
• Provided abuse guidance training to the DON and Administrator