F0607

J

Failure to Report and Investigate Resident-on-Resident Abuse Allegation

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

Penalty

Fine: $9,330

Summary

The deficiency involves the facility’s failure to implement its written abuse, neglect, and exploitation policies by not investigating or reporting allegations of verbal and physical abuse between residents and by not assessing a resident after an alleged abuse incident. One resident, an older female with osteoarthritis, depression, anxiety disorder, Alzheimer’s disease, gait abnormalities, and age-related debility, had a BIMS score indicating moderate cognitive impairment and was care planned for chronic pain and psychosocial risks. Her orders included routine and PRN pain medications and monitoring for pain and depressive features every shift, with documentation showing no pain or behavioral issues noted during the period in question. Despite this, she later reported right shoulder/arm pain and psychological distress related to an interaction with another resident.

On a weekend in late February, the resident and her responsible party (RP) reported to LVN A and CNA A that another female resident in a wheelchair had rammed or bumped her in the dining room, causing her to become upset and fearful. The RP stated the resident was crying, reported being rammed by the wheelchair minutes before the RP’s arrival, and that a bruise was developing on the resident’s elbow; the resident later described the impact as a hard crash from behind that caused severe shoulder pain lasting about a week. The resident reported that the other resident had previously made hateful and inappropriate remarks to her and others, and that after the wheelchair incident she avoided common areas and felt terrified of the other resident. CNA A confirmed that the resident told her she had been hit by the other resident and that the resident became tearful and avoided the dining room when the alleged aggressor was present, but CNA A did not report this allegation to the Administrator/Abuse Coordinator, assuming it was already being addressed because the resident said the nurse and social worker were aware.

LVN A acknowledged that the resident and RP approached her upset about an altercation with the other resident, reporting that the other resident attempted to take the resident’s plate and cup while making hateful remarks and that the resident said she had been bumped by the wheelchair. LVN A stated she did not interpret this as an allegation of abuse, did not report it to the Administrator, and did not assess the resident for injury, despite knowing that all abuse allegations must be reported to the Abuse Coordinator. The social worker, who participated in a care plan meeting shortly after the incident, reported being aware only of a verbal disagreement and not of any physical contact, and therefore did not report abuse concerns. The NP later documented that the resident reported right shoulder pain and stated another resident had run into her with a wheelchair a few days earlier; he interpreted the event as accidental, did not explore it further as a potential abuse incident, and did not order imaging because the resident reported the pain was subsiding.

The other resident involved was an older female with dementia with behavioral disturbances, depression, psychotic disorder with hallucinations, insomnia, muscle weakness, and severe cognitive impairment, who used a wheelchair and could self-propel. Her care plan identified inappropriate behaviors such as storing soiled clothing and linens, placing paper products in briefs, and moving and dragging dining room chairs, with interventions including monitoring and documenting behaviors and observing for early warning signs. She also had an order to monitor target behaviors of confusion or aggression each shift, but the TAR showed no behaviors documented, and there were no progress notes for nearly a month around the time of the incident. However, staff interviews and direct observation showed that she exhibited ongoing disruptive behaviors in the dining room, including moving from table to table, taking items from tables and the floor, pulling on chairs and another resident’s wheelchair, and becoming verbally aggressive when redirected. Despite staff having received in-services on abuse and neglect and the Administrator and DON stating that all allegations should be reported to initiate investigation and ensure resident safety, the Administrator and DON were not informed of the reported physical contact and verbal aggression, and no abuse investigation or immediate assessment of the allegedly injured resident was initiated in accordance with the facility’s Abuse, Neglect, and Exploitation Prohibition policy.

An Immediate Jeopardy situation was identified related to these failures, as the facility did not develop and implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property for the residents reviewed. The facility failed to ensure that staff reported the resident’s allegations of being hit or rammed by another resident’s wheelchair and of ongoing hateful verbal remarks to the Abuse Coordinator, failed to assess the resident promptly after the alleged incident despite subsequent reports of shoulder/arm pain, and failed to document and monitor the other resident’s aggressive and disruptive behaviors as ordered. These actions and inactions resulted in the abuse allegation going unreported and uninvestigated, while the resident continued to experience psychological distress and reported fear related to the other resident’s behavior.