F0600

J

Failure to Protect Residents From Peer-to-Peer Verbal and Physical Abuse in Common Areas

El Campo, Texas Survey Completed on 03-15-2026

Penalty

Fine: $9,330

Summary

The deficiency involves the facility’s failure to protect residents from abuse and neglect and to respond appropriately to allegations and observable patterns of aggressive behavior by one resident toward others. A cognitively impaired female resident with dementia, depression, psychotic disorder with hallucinations, and behavioral disturbances was known to self‑propel in a wheelchair, move around the dining room, take other residents’ plates and cups before they were finished, and rearrange dining room chairs. Her care plan identified inappropriate behaviors such as hoarding soiled clothing and linens, placing paper products in briefs, and dragging dining room chairs, with interventions including monitoring and redirection. Despite a physician order to monitor target behaviors of confusion or aggression each shift, the treatment administration records for multiple months showed no behaviors documented, and progress notes for several weeks contained no entries, even though psychological services notes referenced anxiety, agitation, and verbal or physical aggression as focus areas.

A female resident with osteoarthritis, depression, anxiety, Alzheimer’s disease, gait abnormalities, and chronic pain, who used a wheelchair and had moderate cognitive impairment, reported that the aggressive resident repeatedly made hateful and nasty remarks to her and other residents and that she was terrified of this resident. She described an incident in the dining room in which she was seated when she felt a hard crash from behind as the other resident in a wheelchair struck her, after which the aggressor wheeled away. The resident reported severe right shoulder pain for about a week following the incident, tearfulness, and avoidance of common areas due to fear of encountering the aggressor. A physiatry NP documented that the resident reported right shoulder/arm pain a few days after another resident accidentally backed into her with a wheelchair, with tenderness over the right upper arm and limited abduction, and noted that pain was improving. The resident’s responsible party stated that when she arrived for a visit, the resident was crying and reported being rammed by the wheelchair, that a bruise developed on the elbow, and that the shoulder bothered the resident for about a week. The responsible party also reported prior hateful remarks from the aggressor, including telling residents to go back to where the hell they came from, and ongoing fear and avoidance behaviors by the injured resident.

Another cognitively intact resident reported that about a month earlier, while she was waiting near the kitchen door in the dining room, the same aggressive resident approached in a wheelchair, yelled at her to move, and struck her on the arm with her hand when she did not move. She stated the DON was nearby and believed the DON witnessed the incident, and that the DON told her the aggressor was confused and that this behavior was part of her baseline. This resident began avoiding the aggressor and felt it was not fair that others had to tolerate her behavior. A CNA reported being aware of physical and verbal aggression by the aggressor toward residents and staff and stated that the injured resident had told her the aggressor had hit her and that the injured resident became tearful and refused to enter the dining room when the aggressor was present, preferring to stay in her room. The CNA acknowledged receiving multiple in‑services on abuse and neglect and knowing that all allegations must be reported to the Administrator, but she did not report the allegation because the resident said the nurse and social worker already knew, and she assumed it was being addressed. An LVN recalled the injured resident and responsible party approaching her upset about an altercation in which the aggressor tried to take the resident’s plate and cup while making hateful remarks and bumped her with the wheelchair, but the LVN did not interpret this as an allegation of abuse and did not report it to the Administrator, despite knowing that verbal and physical abuse must be reported.

Facility leadership, including the Administrator and DON, stated they were not aware of any aggressive incidents involving the aggressor and other residents, including the two residents who reported being struck. The Administrator acknowledged knowing that the aggressor frequently attempted to clean the dining room and took trays from residents before they finished eating but denied receiving reports of aggression. The social worker stated she was only aware of a verbal altercation between the aggressor and the injured resident and had not been told that the resident was struck or rammed with a wheelchair, and she described the aggressor’s behaviors as consistent with her cognitive impairment. During surveyor observation in the dining room, the aggressor was seen self‑propelling in her wheelchair from table to table, picking up items, pulling on chairs and tables, and then unlocking another resident’s wheelchair brake and pulling that wheelchair backward away from the table while mumbling, with no staff present in the room at the time. Across interviews and record review, there was no evidence that staff consistently recognized, documented, or reported the aggressive resident’s behaviors as potential abuse, nor that they implemented effective supervision or monitoring in the dining room, resulting in repeated unaddressed incidents of verbal and physical aggression toward other residents and the continuation of the aggressor’s presence in common areas despite expressed fear and distress from affected residents.