F0600

D

Failure to Report and Prevent Ongoing Verbal Abuse Between Residents

El Paso, Texas Survey Completed on 03-12-2026

Penalty

Fine: $124,950

Summary

The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse and to ensure that allegations of abuse were immediately reported to the Administrator. One resident with progressive multiple sclerosis, morbid obesity, and dependence on assistance for ADLs reported that another resident repeatedly called her a “cow” and yelled indirectly at her when passing by her room. She was cognitively intact, oriented, and able to make herself understood. Her care plan documented episodes of adverse behaviors and a potential mood problem related to an incident in which another resident called her a cow, with approaches including behavioral health consultation and monitoring for mood symptoms.

The resident alleged that the verbally aggressive resident yelled at others, called her a cow, and made loud, annoying noises when passing her room, which made her feel anxious and frustrated because staff were not stopping him. A friend of this resident stated that the name-calling and yelling had been occurring for approximately a year and a half, including after the verbally aggressive resident was moved to another hall, and that these behaviors occurred more often on weekends. The friend reported that the resident who was being called names had limited physical strength due to multiple sclerosis and that the verbally aggressive resident threatened to hit her. The friend also stated she had reported these concerns to the Administrator the previous year.

The resident identified as verbally aggressive was cognitively intact, used a wheelchair, and had documented verbal aggression, including insulting male peers and yelling at a roommate about TV volume. His care plan and psychological assessments noted verbal aggression, anxiety, and depressive disorder, with a risk of verbal aggression. Facility records showed prior incidents of altercations and name-calling involving this resident, including an altercation reported to the state and an incident of calling another resident a cow. Despite this history, multiple CNAs and an LVN reported they had not personally witnessed him insulting or name-calling other residents, though they acknowledged he spoke loudly and made other residents uncomfortable.

A key event leading to the deficiency was an incident witnessed by the weekend receptionist approximately one month before her interview. She observed the verbally aggressive resident in the living room playing dominoes and the resident with multiple sclerosis in the reception area when he called her a cow. The receptionist stated this resident had done this before, and she moved the resident with multiple sclerosis at that time. She confronted the verbally aggressive resident and told him not to repeat the behavior, but she did not report the incident to anyone in the facility, despite having been trained via email on abuse, neglect, and exploitation to immediately report verbal abuse to the Administrator. She stated she asked the resident who was called a cow if she wanted it reported, and when the resident said no, she chose not to report it, telling her that if it happened again she would have to report it. The Administrator later stated that staff were expected to immediately report any allegation of abuse, neglect, and mistreatment and that failure to do so placed residents at risk of further abuse.

The facility’s written policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated that residents have the right to be free from abuse, including verbal and mental abuse, and that the program includes protecting residents from abuse by anyone, providing staff training on abuse prevention and reporting, and investigating and reporting any allegations within required timeframes. The failure of the receptionist to immediately report the witnessed verbal abuse incident to the Administrator, in the context of a resident with a documented history of verbal aggression and prior incidents of calling another resident a cow, led to the cited deficiency for not protecting the resident’s right to be free from verbal and physical abuse and not ensuring immediate reporting of abuse allegations.