F0600

J

Abuse and Neglect During Toileting and Transfer Resulting in Resident Fall and Knee Injury

Bastrop, Texas Survey Completed on 03-20-2026

Penalty

Fine: $24,845

Summary

The deficiency involves the facility’s failure to protect a resident from verbal, mental, and physical abuse and neglect during toileting and transfer care. The resident was a 75‑year‑old female with moderate intellectual disabilities, vascular dementia (moderate, without behavioral disturbance), bipolar disorder, and severe cognitive impairment (MDS score of 7). Her care plan and functional assessments documented that she used a wheelchair for mobility, could not take four steps, and required supervision/touching assistance for sit‑to‑stand and bed‑to‑chair transfers, as well as partial to extensive assistance for toileting and transfers. She also had documented communication problems related to a hearing deficit and unclear speech, and a care plan focus on attention‑seeking behaviors with interventions directing staff to speak calmly, divert attention, and ensure a safe environment.

On the evening in question, video footage showed the resident in her bathroom in a wheelchair when an LVN entered, turned the wheelchair toward the grab bar, and instructed the resident to stand, stating she could not lift her. As the resident stood holding the grab bar, the LVN commented that the resident was “doing all that faking” and, when the resident defecated, the LVN reacted by saying “Eww” and “gross,” and later “Jesus Christ” and “oh my God” while leaving the resident standing partially unclothed. The resident then maneuvered herself to sit down hard on the toilet without staff present. Subsequent video segments showed the LVN outside the open bathroom door, within the resident’s hearing, telling a CNA that the resident had “shit everywhere and shit on me” and that the resident thought it was funny. The LVN and CNA discussed the resident’s behaviors, with the CNA stating the resident “knows better” and calling it a behavior problem, and the LVN agreeing and describing the resident as someone who hits and grabs staff.

Further video showed the LVN re‑entering the bathroom, removing the resident’s wheelchair, and telling the resident that what had occurred was the “nastiest shit” she had ever seen, that the resident thought it was funny, and that the resident should be ashamed. While the LVN cleaned the floor and the resident’s feet, the resident began sobbing, and the LVN repeatedly told her to stop crying, stating “what are you crying for shitting yourself,” and telling her she needed to be in a psych ward. Another CNA entered and agreed it was a behavior, and both staff continued to speak derogatorily about the resident in her presence. The LVN and CNA B discussed cleaning the soiled wheelchair and stated the resident would not have a wheelchair and “doesn’t need a wheelchair,” with CNA B telling the resident she was “nasty” and to stop touching herself. The resident was left alone on the toilet sobbing at times while staff were outside the bathroom.

In later video segments, CNA B and the LVN were in the bathroom with the resident, who was sobbing while standing and holding the grab bar as CNA B applied a brief. The LVN told the resident “cry cry cry, shut up, just seriously shut up,” and stated that if the resident went to the psych ward she would not think it was funny, adding “you should cry, nasty” and “you ain’t getting your chair.” Despite the resident’s documented need for wheelchair use and extensive assistance, CNA B held the resident’s arm and directed her to walk from the bathroom to the bed, telling her “you’re walking, hush come walk” while the resident said “no” and continued sobbing. The resident attempted to take a step, fell, and her left knee hit the floor. Subsequent video showed CNA B telling the resident she was not going to get her chair and that she knew how to walk, lifting her to a standing position and escorting her with minimal assistance to the bed while the resident held the wall and pulled up a loose brief. Both staff continued to accuse her of “fake crying” and dismissed her complaints as she rubbed her left knee. A skin assessment later documented bruising to the front left knee acquired in‑house, and a psychiatric assessment noted a contusion on the knee.

The facility’s own records and interviews confirmed that the resident’s care plan and functional status required wheelchair use and assistance for transfers and toileting, and that she was a high fall risk. The ADON and other staff stated they would never ask this resident to walk from the bathroom to the bed and that she had not been known to walk, and that extra wheelchairs were readily available. The administrator and DON, after reviewing the videos, characterized the staff behavior as verbal and physical abuse, including making the resident walk without her wheelchair when she requested it, speaking to her in a demeaning and profane manner, and failing to treat her with dignity and respect. The resident’s responsible party reported receiving multiple distressed calls from the resident stating she was not allowed to have her wheelchair and later observed the wheelchair placed outside the room. A forensic interview video later showed the resident crying when asked if she had been hit, pushed, or left alone in the bathroom. The survey identified this as past noncompliance at the level of Immediate Jeopardy, beginning on the date of the incident and ending several days later.