F0607

J

Failure to Protect Residents From Repeated Resident-to-Resident Abuse

Mcallen, Texas Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, specifically in relation to resident-to-resident aggression. Resident #1, an elderly male with dementia, severe cognitive impairment (BIMS score of 4), generalized anxiety disorder, major depressive disorder, and insomnia, had a documented history of verbal aggression toward staff and other residents. His care plan reflected multiple episodes of resident-to-resident and resident-to-staff verbal aggression prior to the incidents in question. Resident #2, an elderly male with Alzheimer’s disease and moderate cognitive impairment (BIMS score of 11), also had documented behavioral symptoms, including physical and verbal behaviors directed toward others.

On 02/07/26, a resident-to-resident altercation occurred between Resident #1 and Resident #2 at the entrance to their shared room. CNA A reported seeing Resident #1 holding Resident #2’s shirt and striking him with a closed fist once in the jaw and once in the chest while Resident #2 was in his wheelchair attempting to exit the room. CNA A stated she yelled for them to stop and called for help, after which LVN B assisted in separating the residents and took Resident #2 to the common area. CNA A reported to LVN B that she had witnessed the punches and warned that the two residents could not safely remain together because Resident #1 was aggressive and could attack Resident #2. LVN B assessed Resident #2, documented no injuries or pain, and recorded that Resident #2 denied being hit and stated only his wheelchair was struck. The DON and Administrator were notified of the incident and of CNA A’s report that Resident #1 had hit Resident #2, but no abuse investigation was initiated because Resident #2 denied being hit.

Following the first incident, the facility’s response consisted of limited and inconsistently implemented monitoring. CNA A reported she was posted outside the room for about 10 minutes and did not see anyone else sit outside the room afterward. The DON and RN F stated that monitoring and having an aide posted outside the door were used, but the DON acknowledged there was no documentation of monitoring during the night shift and that the only monitoring was what appeared in the chart. No room change or one-to-one supervision was implemented at that time, and the residents continued to share a room. On 02/08/26 at approximately 4:00 a.m., a second incident occurred in which Resident #2 was found on the floor with bilateral arm and right knee skin tears and redness to the bridge of his nose. Staff interviews and documentation indicated that Resident #2 stated his roommate had grabbed him by the arms and pushed him to the floor, and another aide reported seeing Resident #1 standing over Resident #2 holding a bedside table and saying he would hit him again. Both residents were sent to the hospital for evaluation. The DON later stated that because Resident #2 denied being hit after the first incident, the facility did not initiate an abuse investigation and only implemented limited monitoring, and further acknowledged that the second incident could have been prevented had monitoring been continued. This sequence of events demonstrated the facility’s failure to fully implement its abuse policy requiring protection of residents from harm during abuse investigations and prevention of occurrences of abuse.

Removal Plan

• Completed a room change for Resident #1.
• Implemented 15-minute observation checks for Resident #1.
• Sent Resident #1 out of the facility and cancelled the bed hold.
• Implemented a monitoring tool to identify residents with resident-to-resident behaviors and document actions taken to correct behaviors.
• Held an ADHOC QAPI meeting addressing the resident-to-resident incident.
• Updated Resident #1’s care plan to address resident-to-resident aggression.
• Updated Resident #2’s care plan to address resident-to-resident altercations.
• Reviewed and updated care plans for additional identified residents with behaviors with interventions to address behaviors.
• Coordinated psychiatric nurse practitioner involvement to identify residents with behaviors and follow up.
• Ensured psychiatric evaluations occurred for residents with behaviors.
• Conducted facility-wide in-service training for all team members on immediate reporting of abuse, injury, neglect, and exploitation to the Administrator; reporting resident-to-resident aggression and inappropriate touching; redirecting and keeping residents safe; placing residents on one-to-one monitoring; and keeping residents separated.
• Trained staff to report abuse immediately to the Administrator and to separate residents and implement one-to-one monitoring with any resident-to-resident altercation.
• Trained the DON and Administrator on the abuse guidance policy for preventing, identifying, and reporting.