DAINGERFIELD, TX- CAPSTONE HEALTHCARE OF DAINGERFIELD/WINDSOR PLACE

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

LEVEL OF HARM- Immediate jeopardy to resident health or safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19401

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse or neglect for 3 of 7 residents reviewed for abuse. (Resident #1, Resident #3, and Resident #4)

The facility failed to ensure Resident #4 was not verbally abused mentally abused, and harassed for the remainder of the night on 5/28/23 by LVN D

The facility failed to educate staff on the de-escalation of an agitated or aggressive resident.

The facility failed to identify harassment and intimidation as abuse for Resident #1 and Resident #3 when they complained about the care CNA A was providing.

The facility failed to identify abuse when Resident #3 said CNA A intentionally caused her pain.
CNA A was allowed to continue to intimidate and harass Resident #1 by going into her room and the shower room when she was receiving a shower.

An Immediate Jeopardy (IJ) situation was identified on 12/27/23 at 3:00 p.m. while the IJ was removed on 12/28/23 at 8:18 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility’s need to evaluate the effectiveness of the corrective systems.

This failure could place residents at risk of physical harm and or emotional abuse.

Findings included: Record review of Resident #4’s face sheet with no date indicated he was admitted to the facility on [DATE] and discharge 6/2/23. Resident #4 was a [AGE] year-old male with admitting diagnoses of need for assistance with personal care, history of falling, colostomy status, mood disturbance, anxiety, and lack of coordination.

Record review of Resident #4’s admission MDS dated [DATE] indicated the resident had moderate
cognitive
impairment. His functional status indicated he required extensive assist of one person with
transfers, toilet use and dressing. The resident was unable to stand and stabilize himself. He did
not walk. He was unable to move himself off the toilet, and he was not steady with transfers from
surface to surface.

Review of Resident #4’s baseline care plan dated 5/28/23 indicated his cognition was alert and
cognitively intact and required one person assist with bed mobility, transfers walking in toileting
. The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision.
He had a new colostomy with interventions to teach the resident proper changing techniques and
monitor site of colostomy.

Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the
morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on
Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I’ll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident’s room was searched and there was no knife found.

Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse’s station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the
aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a
statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night.

Record review of a statement that accompanied the Provider Investigation Report for Resident # 4
indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4’s A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C.

Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23.

During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4’s room on morning of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse’s behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and
leave.

During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D.

During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses’ behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1’s face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer’s, disease, anxiety disorder, and history of falling.