F0656

G

Failure to Implement Behavior Care Plan and Identify Triggers for Aggressive Resident

Houston, Texas Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s physical behaviors. Resident #2, an individual with encephalopathy, aphasia, hemiplegia/hemiparesis following cerebral infarction, bipolar disorder, anxiety disorder, and moderate cognitive impairment (BIMS 9), had a care plan dated 8/26/24 identifying a potential to demonstrate physical behaviors related to agitation and combativeness, with a history of alleged physical aggression on 12/16/24, 8/8/25, and 9/26/25. The care plan interventions included a psych consult, analysis of key times, places, circumstances, triggers and de-escalators, and providing cues and choices. Despite this, the facility did not carry out the required analysis of circumstances and triggers after subsequent physical abuse incidents.

On 8/8/25, documentation showed that Resident #2 suddenly slapped another resident (Resident #3) in the face while trying to get by in the hallway. The Provider Investigation Report indicated that the receptionist reported Resident #2 slapped Resident #3 after “having words,” and the Administrator’s interview with Resident #2 revealed he hit Resident #3 because he did not like what he said. Resident #3 reported they argued and Resident #2 hit him in the face. A later telephone interview with the former receptionist clarified that Resident #3 was sitting in his usual spot along the wall, Resident #2 wanted the same spot, they argued, and Resident #2 then leaned in and hit Resident #3 with a closed fist. The investigation report did not document any analysis of the circumstances or triggers surrounding this incident, despite the care plan requirement to do so.

On 9/26/25, a progress note documented that Resident #2 got out of his wheelchair, walked up to another resident (Resident #1), and hit him in the face with his fist, stating the other resident was “always messing with me.” The Provider Investigation Report recorded that the Activity Director reported Resident #2 punched Resident #1, and that Resident #2 told the Administrator he hit Resident #1 because he was always “messing with him,” while Resident #1 stated he was on his phone and did not say anything to Resident #2. Subsequent interviews revealed that Resident #1 had limited mobility in his arms and hands and described Resident #2 walking across the patio and swinging at him after misinterpreting a phrase spoken into his phone. Staff interviews, including with CNAs, the DON, Social Worker, and MDS nurse, showed that while some staff were aware of a history of physical abuse, they were not aware of specific triggers or circumstances that could cause Resident #2 to become physically abusive, and the DON and Administrator acknowledged that triggers had not been identified or assessed after the incidents. This demonstrated that the care plan intervention to analyze circumstances and triggers after physical behavior incidents was not implemented.