F0609

D

Failure to Report Alleged Abuse and Suicidal Ideation Within Required Timeframes

San Antonio, Texas Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report alleged abuse and suicidal ideation to the administrator and State Survey Agency as required by policy and federal regulations. On one occasion, a resident with Alzheimer’s disease, anxiety, depression, and severe cognitive impairment (Resident #4) was alleged to have slapped her roommate (Resident #5) in the face while the roommate was eating breakfast in their shared room. A registered nurse documented that when she entered the room, the roommate warned her to be careful because the other resident had slapped her. The nurse separated the two residents, assessed them, and documented that vital signs were stable and no injuries were observed. An incident report was completed describing the resident-to-resident altercation and the immediate actions taken, including placing one resident in front of the nurse’s station, but this allegation of physical abuse was not reported to the State.

A second incident involved suicidal ideation by Resident #5, who had diagnoses including Alzheimer’s disease, major depressive disorder, recurrent suicidal ideations, repeated falls, and a cognitive communication deficit. A nurse’s progress note documented that another nurse reported hearing this resident state, “I am going to kill myself,” while walking down the hallway. The nurse immediately located the resident, assessed for safety, and documented that the resident denied making the statement and denied any suicidal ideation, intent, or plan, appearing calm and in good spirits with no signs of emotional distress. A psychiatric mental health nurse practitioner later documented that the resident had been placed on 1:1 observation after it was reported she voiced wanting to kill herself, that the resident denied current suicidal ideation and any plan or intent, and that the resident stated she had made the statement because she was upset but did not mean it. Despite these documented reports of suicidal statements and the resident’s history of suicidal ideations, this incident was not reported to the State as an allegation of abuse or neglect.

Interviews with facility staff and leadership confirmed that these events were treated as internal incidents but not reported externally as required. The Regional Nurse acknowledged awareness of the resident-to-resident incident in which one resident accused her roommate of slapping her, and stated that after assessments showed no injuries and no witnesses, she recommended not reporting the incident to the State. She also stated that the suicidal ideation incident was assessed and followed by multiple clinicians, and that she did not believe it required State reporting. The MDS Coordinator similarly stated that the interdisciplinary team reviewed the physical and verbal incidents and the suicidal ideation but did not believe they required reporting. The Senior Director, however, stated that if a resident reported another resident was physically aggressive or expressed wanting to hurt themselves, this would warrant an abuse report. The former administrator reported she was not informed of the suicidal ideation incident or the later resident-to-resident incident and stated that, had she been made aware, she would have reported them to the State. Facility policy on Abuse, Neglect and Exploitation required immediate investigation of suspected abuse and reporting of all alleged violations to the administrator and state agency within specified timeframes, including within two hours for allegations involving abuse, but these procedures were not followed for the two incidents involving Residents #4 and #5.