F0609

D

Failure to Timely Report Resident-to-Resident Abuse Allegation to State Agency

Mcallen, Texas Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report an alleged resident-to-resident abuse incident to the state agency and appropriate officials within the required 2-hour timeframe. On the date in question, Resident #2 was found on the floor of his room at approximately 4:00 a.m., calling for help. A CNA entered the room and found Resident #2 on the floor with skin tears on both arms and the right knee. Resident #2 stated that his roommate, Resident #1, had pushed or pulled him down. Nursing documentation by LVN D and RN J identified bilateral antecubital skin tears, a right knee skin tear, and a red discoloration on the bridge of the nose, with Resident #2 reporting arm pain but denying emotional distress. Resident #2 was assessed, transferred to the hospital, and later returned with no fractures or critical findings noted in the hospital records.

Resident #1’s records showed a history of dementia with severe cognitive impairment (BIMS score of 4), generalized anxiety disorder, major depressive disorder, and insomnia, with documented episodes of verbal aggression toward staff and other residents, and prior resident-to-resident verbal aggression. The care plan and IDT documentation reflected multiple prior behavioral incidents, including resident-to-resident verbal aggression on several dates and an entry on the date of the incident indicating resident-to-resident physical and verbal aggression. An IDT ABC tool completed by LVN D on the date of the incident documented that at 4:00 a.m. Resident #1 was standing over his roommate with a table and was upset, stating he would hit the roommate again.

Resident #2’s records reflected Alzheimer’s disease with moderate cognitive impairment (BIMS score of 11) and a history of behavioral symptoms, including physical and verbal behaviors directed toward others. His care plan noted prior resident-to-resident physical altercations on the day before and the day of the incident. The Administrator, who served as the abuse coordinator, stated she was notified by LVN D at approximately 5:00 a.m. of the altercation and injuries but did not report the allegation to HHSC until 5:00 p.m., well beyond the 2-hour requirement. She acknowledged that the altercation should have been reported within 2 hours and that facility policy, consistent with HHSC PL 19-17, required alleged or suspected abuse to be reported immediately, but not later than 2 hours after the allegation is made, when the events involve abuse or result in serious bodily injury. The Administrator stated she reported late because she was busy conducting interviews.