F0607

K

Failure to Implement Abuse Reporting and Protection Policies for Resident-to-Resident Incidents

Lumberton, Texas Survey Completed on 03-26-2026

Penalty

Fine: $57,750

Summary

The deficiency involves the facility’s failure to implement its written abuse prohibition policies and procedures to identify, report, and protect residents from abuse, specifically in relation to two cognitively intact residents who were in a relationship and shared a room. The facility’s Abuse Prohibition Policy defined abuse to include physical, mental, and verbal abuse, and required that any allegation of abuse made by residents, staff, or visitors be reported immediately to the Abuse Coordinator and investigated. The policy also required immediate protection of residents, monitoring of staff and resident behaviors to identify potential abuse, and specific steps for resident‑to‑resident incidents, including separating residents, assessing for injury, notifying the physician and family, completing incident reports, and contacting the Abuse Coordinator.

One resident, an adult male with paraplegia, major depressive disorder, and anxiety disorder, and another resident, an adult female with cerebral infarction, severe visual impairment, bipolar disorder, and anxiety disorder, both had intact cognition with BIMS scores of 15/15 and had requested to room together. The male resident had care plan entries documenting a history and potential for verbally aggressive and accusatory behavior toward staff and residents, and episodes of verbal aggression/irritability when care for his girlfriend/roommate was not provided immediately. On one occasion, nursing notes documented that the female resident reported crying and being upset because her boyfriend yelled at and belittled her in front of others, and she expressed a desire to move out of the shared room. The LVN reported this to the social worker, who spoke with the resident; the resident later recanted and stated she loved him, and the male resident stated he had only told her to tell the nurse about her stomach pain. The Administrator was aware of this incident but, based on the recantation, did not consider it reportable and did not treat it as an abuse allegation under the policy.

On a subsequent date, a CNA completed a written witness statement indicating she had observed the male resident yell at the female resident and call her a derogatory term, specifically “[f‑ing retard].” The CNA believed the Abuse Coordinator would see this in the statement, but the Administrator later stated she had not seen that portion of the statement. The Administrator acknowledged that such language would constitute verbal abuse and would be reportable to the state agency, yet the incident was not reported to the Abuse Coordinator or to the state agency as required by policy. Later, both a CNA and a medication aide witnessed the male resident pushing the female resident in her wheelchair and shoving her into trash and dirty linen barrels in the hallway. Both staff members stated they did not consider this to be abuse and therefore did not report it to the Administrator or Abuse Coordinator. The Administrator reported she was unaware of this physical incident until informed by the CNA shortly before the surveyor interview and acknowledged that it could be considered physical abuse and would be reportable. These failures to recognize, report, and respond to resident‑to‑resident verbal and physical abuse incidents, despite clear policy requirements and prior knowledge of the male resident’s behavioral history, led to the cited deficiency and the identification of an Immediate Jeopardy situation.