F0607

G

Failure to Implement Abuse Prevention Policies for Resident-to-Resident Aggression

Houston, Texas Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its written abuse prevention policies and procedures for two residents with known behavioral and vulnerability issues. The facility had an Abuse Prevention Program policy dated August 2006 stating residents have the right to be free from abuse and that comprehensive policies and procedures were developed to prevent abuse, neglect, or mistreatment, including identification of occurrences and patterns of potential mistreatment/abuse and implementation of changes to prevent future occurrences. Despite this, the facility did not effectively apply these policies when one resident with a history of physical aggression assaulted another resident and when the same two residents were later placed in close proximity to each other.

One resident (Resident #2) had multiple neurological and psychiatric diagnoses, including encephalopathy, aphasia, hemiplegia/hemiparesis following cerebral infarction, bipolar disorder, and anxiety disorder. His quarterly MDS showed moderate cognitive impairment (BIMS 9), use of a wheelchair with some independent mobility, and behavioral symptoms. His care plan documented a potential to demonstrate physical behaviors related to agitation and combativeness, with prior alleged physical aggression toward other residents on 12/16/24, 8/8/25, and 9/26/25, and a separate behavior problem of rummaging through other residents’ rooms. On 9/26/25, a progress note documented that he suddenly got out of his wheelchair, walked up to another resident (Resident #1), and hit him in the face with a closed fist, stating he did so because the other resident was “always messing with” him. He was subsequently transferred to the local county jail and later readmitted to the facility.

The other resident (Resident #1) had quadriplegia, epilepsy, bipolar disorder, and major depressive disorder, with no cognitive impairment (BIMS 15) but documented verbally abusive behaviors such as yelling and cursing at staff and his roommate on most days. He was dependent on staff for personal hygiene and transfers, used a motorized wheelchair independently, and had limited mobility in his arms and hands. On the day of the physical altercation, he was sitting on the patio using his phone when Resident #2, seated on the other side of the patio, stood up, walked across the patio, and began swinging at him, causing facial pain. A head-to-toe assessment noted pain to the left side of his face, and hospital records documented he was seen for an alleged assault with discharge instructions for a facial bruise. Later, after Resident #2 was readmitted, the facility moved Resident #2 to a new room four doors down and across the hall from Resident #1 at the end of a dead-end hallway. Resident #1 reported that staff did not speak to him when Resident #2 was moved to his hallway, that Resident #2 now sat outside his room and looked in, and that he did not like this arrangement. These actions and inactions demonstrate the facility’s failure to implement its abuse prevention policies by not preventing the initial assault and by subsequently placing the two residents in close proximity after a known resident-to-resident assault.