CARTHAGE, TX- CARTHAGE HEALTHCARE CENTER

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44933

Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse.

The facility failed to prevent LVN A, on 12/10/23, from verbally and physically abusing Resident #1 when she used foul language and threw ice at Resident #1.

The facility failed to prevent LVN A, on or about 12/10/23, from verbally and physically abusing Resident #2 when she used foul language and threw an object at Resident #2.

The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023.

The facility had corrected the noncompliance before the survey began.

These failures could place resident at risk for emotional distress, fear, decreased quality of life and further abuse.

Findings included:
1.Record review of Resident #1’s face sheet, dated 07/08/24, indicated Resident #1 was a [AGE] year-old, male admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mood affective disorder (is any of a group of conditions of mental and behavioral disorder where a disturbance in the person’s mood is the main underlying feature), and mild cognitive impairment (is the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia).

Record review of Resident #1’s quarterly MDS assessment dated [DATE] indicated Resident #1 was
sometimes understood and sometimes had the ability to understand others. Resident #1 had minimal difficult hearing, clear speech, and adequate vision. Resident #1 had a BIMS score of 03 which indicated severe cognitive impairment. Resident #1 required supervision for ADL assistance except for shower/bathe self which required maximal assistance.

Record review of Resident #1’s care plan dated 04/19/23 indicated Resident #1 was at risk for altered psychosocial well-being related to dementia. Intervention included listen carefully and be non-judgmental.

Record review of a PIR for Resident #1, dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m .LVN A used foul language and threw ice at a resident .LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to ‘stop fucking looking at me and go on’ and threw a piece of ice at him .MA D stated that she heard LVN A say ‘stop fucking looking at me and go on’ but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff .Resident safe surveys did not indicate any concerns with LVN A .physician and RP for Resident #1 notified of the incident .investigation
findings: unconfirmed .Provider action taken post-investigation: staff reeducated on Abuse and Neglect Prevention and reporting, Professionalism, and Resident Rights .5 random staff interviews and resident safe surveys will be conducted monthly and results will be reviewed by QAPI committee monthly for 3 months .

2. Record review of Resident #2’s face sheet, dated 07/08/24, indicated Resident #2 was a [AGE] year-old, male admitted on [DATE] and discharge 06/19/24 with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities), Type 2 diabetes (s a chronic condition that happens when you have persistently high blood sugar levels), nicotine dependence, schizoaffective disorder, bipolar type (is a chronic mental health condition characterized primarily by symptoms of schizophrenia (is a serious mental health condition that affects how people think, feel and behave), such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and restlessness and agitation.

Record review of Resident #2’s annual MDS assessment dated [DATE], indicated Resident #2 was usually understood and usually understood others. Resident #2 had moderate difficulty hearing, clear speech, and impaired vision with use of corrective lenses. Resident #2 had a BIMS of 09, which indicated moderate cognitive impairment. Resident #2 required set up assistance for eating, dressing, and personal hygiene, supervision assistance for oral and toilet hygiene and partial assistance for shower/bathe self.

Record review of Resident #2’s care plan dated 06/12/23, indicated:

*Resident #2 was at risk for altered psychosocial well-being related to schizoaffective disorder. Intervention included listen carefully and be non-judgmental.

*Resident #2 was at risk for altered mood state related to schizoaffective disorder. Resident #2 pace the halls frequently, visit multiple staff members, frequently in/out of office. Resident #2 am easily agitated, yell loudly, make threatening statements to staff and/or residents. Intervention included be reassuring and listen to concerns.

During an interview on 07/09/24 at 9:29 a.m., CNA E said she had worked at the facility for [AGE] years. She said she had witnessed LVN A being loud and heard LVN A used inappropriate language at residents. She said LVN A would escalate situations with Resident #2. She said she heard LVN A had cussed at Resident #1 and Resident #2. She said she did not work the day of LVN A and Resident #1 incident. She said cussing and throwing things at resident was abuse. She said LVN A talked ugly, and, in a way, she would not want her family members spoken to. She said after LVN A and Resident #2 would get into, Resident #2 would talk aloud to himself and stated he did not like LVN A.

During an interview on 07/09/24 at 10:52 a.m., MA D said she worked for the facility for 2 years. She said she worked the day LVN A cussed at Resident #1. She said Resident #1 said or did something at the nursing station where LVN A was sitting. She said LVN A threw ice at Resident #1 and used the F word towards him. She said Resident #1 liked to touch people and grab drinks so maybe he did something to set her off. She said Resident #1 was walking away from LVN A and she threw ice at him. She said LVN behavior was abusive and inappropriate. She said Resident #2 was at the nursing station and was asking LVN A to take him out to smoke. She said LVN A and Resident #2 exchanged words because she did not take him out. She said LVN A had made a sign on a posted note that said, get the fuck away or go away, leave me alone and would put it up when Resident #2 came to the nurses’ station. She said about the second time Resident #2 came to the nurses’ station, LVN A cussed at him and threw the posted note at him. She said Resident #2 walked away and was upset. She said another staff member took him out to smoke. She said this incident happened around the same time of Resident #1’s incident. She said LVN A escalate situation especially with Resident #2. She said using foul language at resident was abusive.

During an interview on 07/09/24 at 11:15 a.m., the ADM said the incident with LVN A and Resident #1 happened on a Sunday. She said on Monday, [NAME] B and DA C told her Resident #1 walked up to the nurses’ station and LVN A cussed at him and threw something at him. She said LVN A may have also called him a wierdo. She said [NAME] B and DA C said the situation bothered them, so they reported it, the next day. She said LVN A denied the event happened. She said she believed the incident with LVN A and Resident #2 happened the same day as Resident #1’s incident with LVN A. She said she recalled being told LVN A held up a sign at Resident #2 but did not remember anything else about foul language being used between them.

On 07/09/24 at 1:10 p.m., called LVN A and left message. LVN A did not return call before or after exit.

During an interview on 07/09/24 at 1:45 p.m., [NAME] B said Resident #1 was at the nurses’ station and LVN A told Resident #1 go the fuck away and threw ice at him. She said Resident #1 did say anything because he was not very verbal, but he was visibly upset by his facial expression. She said Resident #1 walked away from the nurses’ station away from LVN A. She said she considered what LVN A did to Resident #1 was verbal abuse.

During an interview on 07/09/24 at 4:15 p.m., DA C said LVN A threw ice and said get the fuck away from me to Resident #1. She said Resident #1 looked upset like anyone else would if they got ice thrown at them.

During an interview on 07/10/24 at 11:50 a.m., the ADM said she recalled MA D telling her LVN A was on a roll that day and LVN A had a sign telling Resident #2 to go away. She said LVN A egged Resident #2 on all the time. She said if LVN A threw something at Resident #2, she was surprised Resident #2 did not attack LVN A. She said maybe she misinterpreted the situation when MA D told her about LVN A and Resident #2. She said maybe she thought MA D was talking about LVN A and Resident #1’s incident. She said she was the abuse coordinator, and it was her responsibility to investigate and report allegations of abuse to the State.

Record review of LVN A’s annual training dated 06/01/23 indicated training on subjects of resident rights and abuse and neglect.

Record review of a facility conducted in-service, Abuse Prevention Program dated 12/11/23 reflected all employees were provided education of the topic.

Record review of a facility conducted in-service, Reporting Allegations of Abuse, Neglect, and Exploitation dated 12/11/23 reflected all employees were provided education of the topic.

Record review of a facility conducted in-service, Resident Rights dated 12/11/23 reflected all employees were provided education of the topic.

Record review of 13 resident safe surveys dated 12/12/23-12/14/23 indicated no resident had a staff member curse at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility.

Record review of 29 staff interviews dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse.

Record review of LVN A’s Employee Corrective Action Form dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 .incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee’s comments: the ADM and DON
attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, ‘if I’m fired just let me know so I can find another job’. This ADM responded with ‘after we concluded the investigation and spoke to HR, we’ve decided to terminate your employment.’ LVN A did not respond .DON 12/15/23 .ADM 12/15/23 .

Record review of LVN A’s Notice of Termination dated 12/18/23, indicated .LVN A .termination date 12/18/23.reason of termination: abusive language toward resident .is employee eligible for rehire: No .Record review of LVN A’s personnel file indicated hire date of 10/18/22. The facility had performed background check and employee misconduct search. No concerns were identified.

Record review of a facility’s Abuse Prevention policy revised 01/09/23 indicated .our residents have the right to be free from abuse, neglect .this includes but is not limited to .verbal, mental, sexual, or physical abuse .

The administrator was notified of PNC IJ on 07/09/2024 at 4:40 p.m. due to the above failures.

The administrator was provided with the IJ template on 07/09/2024 at 4:45 p.m.

The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy on (12/15/23) by:

– Reviewed completed facility self-reported incident to HHSC for Resident #1 which indicated the following:

* dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m .LVN A used foul language and threw ice at a resident . LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to ‘stop fucking looking at me and go on’ and threw a piece of ice at him .MA D stated that she heard LVN A say ‘stop fucking looking at me and go on’ but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff .

– Reviewed paperwork indicating LVN A was suspended until completion of investigation which indicated the following:

* dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 . incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee’s
comments: the ADM and DON attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, ‘if I’m fired just let me know so I can find another job’. This ADM responded with ‘after we concluded the investigation and spoke to HR, we’ve decided to terminate your employment.’ LVN A did not respond .DON 12/15/23 .ADM 12/15/23 .

– Reviewed termination paperwork for LVN A which indicated the following:

*dated 12/18/23, indicated .LVN A .termination date 12/18/23 .reason of termination: abusive language toward resident .is employee eligible for rehire: No .

– Reviewed LVN A’s time sheet to verify last day worked which indicated the following:

* dated 12/01/23-12/31/23, indicated LVN A last day worked was 12/10/23

– Reviewed employee corrective action form for [NAME] B, DA C and MA D which indicated the following:

*dated 12/11/23, indicated .Employee Corrective Action Form for [NAME] B C .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .Cook B .ADM .

* dated 12/11/23, indicated .Employee Corrective Action Form for DA C .verbal coaching .facility
policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .DA C .ADM .

* dated 12/11/23, indicated .Employee Corrective Action Form for MA D .verbal coaching .facility
policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .

– Reviewed in-service and sign in sheet on Abuse Prevention for all staff which indicated the following:

* dated 12/11/23 reflected all employees were provided education of the topic.

– Reviewed in-service and sign in sheet on Reporting Abuse Allegation for all staff which indicated the following:

*dated 12/11/23 reflected all employees were provided education of the topic.

– Reviewed in-service and sign in sheet on Resident Rights for all staff which indicated the following:

* dated 12/11/23 reflected all employees were provided education of the topic.

– Reviewed completion of notification of RP which indicated the following:

*dated 12/15/23, the PIR, reflected responsible party for Resident #1 was notified of incident

– Reviewed completion of notifying physician of incident which indicated the following:

* dated 12/11/23, the PIR, reflected the physician was notified of the incident involving Resident #1.

– Reviewed staff surveys results concerning LVN A which indicated the following:

* dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse.