F0580

D

Failure to Notify Physician and Representatives After Allegations of Abuse and Staff Altercation

Llano, Texas Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately consult with residents’ physicians and representatives when there were significant changes in residents’ physical, mental, or psychosocial status, including allegations of abuse and exposure to a staff altercation. For one resident (R#1), who had hemiplegia, thrombocytopenia, psychotic disorder with hallucinations, dementia, and socially inappropriate behaviors requiring antipsychotic medication, the facility did not notify her physician or responsible party following two separate incidents on 2/27/26 and 3/5/26 in which she alleged staff were abusive to her. Although an investigation was conducted for at least one of these incidents, there was no documentation that the nurse practitioner (NP) or the resident’s representative were notified, and the responsible party later reported he had not been informed of any such incidents.

The deficiency also includes the facility’s failure to notify the physicians and representatives of two other residents (R#2 and R#3) after they were within hearing distance of a verbal altercation between CNAs on 2/20/26. R#2 had unspecified dementia without behavioral disturbance, psychotic disturbance with hallucinations, anxiety, a language disorder, and was on hospice care, fully dependent on staff for activities of daily living and receiving antidepressants and opioids. R#3 had essential hypertension, major depressive disorder, generalized anxiety disorder, dementia with severely impaired cognition (BIMS of 3), was on palliative care, fully dependent on staff for activities of daily living, and was receiving antidepressants and anticonvulsants. The DON stated that physical assessments were completed for both residents and no injuries were noted, but she could not confirm that their NPs or representatives were notified of the event.

Interviews with staff confirmed that the facility’s protocol required nurses to assess residents involved in incidents and to notify the administrator (ADM), DON, NP, and residents’ representatives. LVN A and LVN B both described this protocol but were not on duty during the incidents and could not explain why notifications were not made. The DON acknowledged that for the 2/27/26 incident involving R#1, the NP and representative were not notified and that this step was missed. The ADM reported attempts to contact R#1’s son by phone but could not explain the lack of NP and representative notification and stated that documentation of such notifications was expected in the Provider Investigation Report, which did not contain this information. Review of the facility’s Accidents/Incidents policy and related in-service topics showed that every incident was to be documented and that family, DON, and provider were to be notified every time, which did not occur in these cases.