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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30527

Based on interviews and record review, the facility failed to ensure the right of the residents to be free from abuse for 2 of 4 residents (Resident #2, Resident #3) reviewed for abuse.

The facility failed to protect other residents from being kicked by Resident #1, when Resident #1 kicked Resident #3’s feet when he walked by him on 1/12/25 at 5:20 am.

The facility failed to recognize and put measures in place for Resident #1’s increased behaviors from 01/09/2025 through 01/12/2025, which resulted in Resident #1 choking Resident #2.

An Immediate Jeopardy (IJ) was identified on 02/27/2025 at 1:40 PM. The IJ template was provided to the facility on [DATE] at 1:06 p.m. While the IJ was removed on 02/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility’s need to complete in-service training and evaluate the effectiveness of the corrective systems.

These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Findings included:
Record review of a face sheet dated 02/27/2025 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including depression, hypercholesterolemia (high blood cholesterol that limits blood flow), hypertension (high blood pressure), delusional disorders (mental illness that causes people to have false beliefs), and dementia (degenerative brain disease – loss of memory, language).

Record review of the comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS score of 0 and was severely cognitively impaired. Resident #1’s MDS indicated wandering behavior was exhibited, and physical and verbal behaviors towards others. Resident #1 was not assessed due to medical condition or safety concerns for eating, toileting, showering, dressing and personal hygiene, ambulation, or transfers.

Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #1 had an order for behavior monitoring for Diazepam,(medication used to treat anxiety, muscle spasms, and seizures) Seroquel (medication used to treat schizophrenia (disorder that affects a person’s ability to think clearly), bipolar disorder (mood swings) and depression), Trazodone (medication used to treat depression) , and Wellbutrin (medication used to treat depression). Document number of times the resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 09/25/2024.

Record review of the care plan with a revision date of 01/15/2024 indicated Resident #1 had the potential to be physically aggressive related to dementia with the following interventions Administer medications as ordered after attempting non-medical approaches, analyze times of day, places, circumstances, triggers and what de-escalates behavior, anticipate needs such as food, water, toileting, if behavior is threat to self or others immediately call for assistance. If signs of agitation shown – intervene before it escalates: remain calm, stand out of reach, listen and respond with empathy, engage in conversation. If response is aggressive, team member to calmly walk away, ask others to leave, ensure everyone is safe, immediately report this to nurse.

Record review of the facilities Incident and Accidents Report dated 10/01/2024 – 01/26/2025 indicated no reported incidents involving Resident #1 and Resident #3.

Record review of a progress note dated 01/09/2025 at 2:07 PM by LVN A, indicated Resident #1 had behaviors with 2 other residents without physical contact.

Record review of a progress noted dated 01/09/2025 at 08:38 PM by LVN B, indicated Resident #1 snatched a cover off another resident in the commons area of the secured unit. Resident #1 swung at staff when approached.

Record review of progress noted dated 01/09/2025 at 08:40 PM by LVN B, indicated Resident #1 was going into other resident’s rooms. Resident #1 raised his hand to the nurse and then walked out of the room.

Record review of progress note dated 01/09/2025 at 09:09 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor. Resident #1 was given a pillow and covered with a blanket.

Record review of progress note dated 01/09/2025 at 09:19 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor then got up and started pacing from door to door, shaking the doors. The ADON and the DON were notified of the behaviors.

Record review of progress noted dated 01/12/2025 at 01:42 AM by LVN F, indicated Resident #1 was exit seeking, restless, and in and out of other resident’s rooms. Resident #1 removed his pants in the commons area in the secured unit.

Record review of progress note dated 01/12/2025 at 05:20 AM by LVN F, indicated Resident #1 (as he walked by) kicked Resident #3’s feet while he was sitting in his wheelchair. Resident #1 was going in other resident rooms and pacing the secured unit.

Record review of progress noted dated 01/12/2025 at 07:00 AM by LVN C, indicated Resident #1 was up and pacing. Resident #1 was grabbing other resident’s wheelchairs and attempting to move them. Resident #1 was crawling in hallway. Resident #1 continued to disturb other residents.

Record review of progress noted dated 01/12/2025 at 08:40 AM by LVN C, indicated Resident #1 was entering rooms, busting in doors, combative with staff, required assistance by two staff members to remove from room. Resident #1 continued to push and pulled on other resident’s wheelchairs. Resident was unable to be redirected. The MA reported Resident #1 continued to refuse his medications with multiple approaches. Resident #1 shoved LVN C in the chest then knocked the medication cup from LVN C. LVN C notified the Administrator, the DON, and the ADON of unable to control/redirect Resident #1, and the escalating behaviors. LVN C then notified Resident #1’s family.

Record review of progress note dated 01/12/2025 at 08:50 AM by LVN C indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2’s room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1’s hands/fingers off Resident #2’s neck and restrain him to the floor. When LVN C entered Resident #2’s room, Resident #1 was restrained by CNA D. Immediate notification made for 911 services. The family was notified of escalating behaviors and transfer and agreed to the transfer.

Record review of a face sheet dated 02/27/2025 indicated Resident #2 was a 75 -year-old female, admitted to the facility on [DATE], with diagnoses including neuralgia (pain associated with nerves), weakness, age related physical debility, dementia (degenerative brain disease – loss of memory, language), and anxiety (intense, excessive worry).

Record review of the comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS score of 3 and was severely cognitively impaired. Resident #2’s MDS indicated she required set up assistance with eating, partial assistance with personal hygiene, and substantial assistance with  toileting, dressing, and showering. Resident #2’s MDS indicated she was independent with ambulation.

Record review of the consolidated physician orders dated 02/27/2025 indicated Resident 2 had an order to monitor for pain every shift.

During an interview with the DON on 2/27/2025 at 10:10 AM , a copy of the Resident’s #2 care plan was requested and not received prior to exiting the facility.

Record review of progress note dated 01/12/2025 at 08:50 AM by LVN A indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2’s room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1’s hands/fingers off Resident #2’s neck and restrain him to the floor. When LVN C entered Resident #2’s room, Resident #1 was restrained by CNA D. CNA E was summoned to Resident #2’s room and escorted Resident #2 from the room. Resident #2 was taken to a chair in the commons area of the memory care unit. Resident #2 was upset and crying. Assessment completed with vital signs within normal limits, oxygen saturation at 97%, no redness or bruising noted, and no petechia observed to bilateral eyes. Police officer and EMT arrived at the facility. The EMT completed a full assessment of Resident #2 until Resident #2 stopped the EMT and stated’ I am fine. Resident #2 assured the EMT she was safe and could return to her room. Resident #2’s family member arrived at the facility and took Resident #2 via private care to the hospital emergency room for evaluation. The Administrator and the DON were made aware of reportable to state.

Record review of hospital discharge paperwork dated 01/12/2025 indicated Resident #2 was discharged with unremarkable findings.

Record review of a face sheet dated 02/27/2025 indicated Resident #3 was an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including hypoglycemia (low blood sugar), type 2 diabetes mellitus (chronic disease when the body does not make insulin properly) mixed hyperlipidemia (causes high levels of cholesterol in the blood), hypertension (high blood pressure), and Alzheimer’s disease (a progressive disease that destroys memory and other mental functions).

Record review of the discharge MDS dated [DATE] indicated Resident #3 had a BIMS score of 0 and was severely cognitively impaired. Resident #3’s MDS indicated wandering behavior was exhibited, physical and verbal behaviors towards others. The MDS indicated Resident #3 required set up assistance for eating. The MDS indicated Resident #3 required partial/moderate assistance for oral and toileting hygiene, partial assistance for shower, dressing, personal hygiene, ambulation, and transfers.

Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #3 had an order for behavior monitoring for Seroquel (medication used to treat schizophrenia (disorder that affects a person’s ability to think clearly) Document number of times resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 01/06/2025.

During an interview with the DON on 2/27/25 at 10:10 AM, a copy of the Resident #3’s care plan was requested and not received prior to exiting the facility.

Record Review of Resident #3’s progress notes dated 01/12/2025 indicated no incidents or assessments completed. Attempted interview on 02/25/2025 at 11:32 AM with Resident #2, she was not interview able.

During an interview on 02/26/2025 at 09:30 AM, LVN C stated she had worked at the facility for approximately 2 years. LVN C stated Resident #1 was an elopement risk from another facility and required the secured unit. LVN C stated on 01/12/25 at 08:50 AM she received a telephone call from CNA E, to come to the secured unit to Resident #2’s room. LVN C stated upon arrival CNA D had restrained Resident #1 on the floor. CNA E had removed Resident #2 to the commons area of the secured unit. LVN C stated she notified 911 for assistance. LVN C stated upon arrival of the police and the EMT, Resident #1 was transferred out of the facility. LVN C stated she completed an assessment on Resident #2. LVN C stated Resident #2 was upset and crying but then stated she was fine and declined any further care. LVN C stated Resident #2’s family arrived and transported her to the emergency room via a private car. LVN C stated Resident #1’s behaviors had escalated from the start of her shift at 06:00 AM. LVN C stated Resident #1 disturbed other residents by pulling on wheelchairs, walked with a rapid pace, crawled on the floors. LVN C stated she had not notified the physician of the increase of behaviors. LVN C stated she had contacted Resident #1’s family at 08:40 AM. LVN C stated she contacted the ADON and the DON regarding Resident #1’s escalated behaviors at 08:40 AM. LVN C stated, I guessed the ADON and DON were working to have the resident transferred out. LVN C stated she was not sure who was making the transfer arrangements at that time. LVN C stated she had reached out to the ADON and the DON via text message and neither were in the facility at that time. LVN C stated she could not recall what exactly she had been told by the ADON and the DON other than redirect Resident #1, but she would have charted the instructions received if she had received any. LVN C stated everything was happening very quickly and she had not delegated any 1 to 1 intervention because the facility did not have the staff. LVN C stated Resident #1 should have been transferred out to a behavioral unit due to escalating behaviors. LVN C stated 1 to 1 intervention could have prevented the choking incident between Resident #1 and Resident #2 but there was not enough staff. LVN C stated Resident #1 was not adequately monitored during the escalated behaviors that resulted in Resident #2 being choked while she was asleep in her bed.

During an interview on 02/26/2025 at 10:21 AM, CNA E said Resident #1 had escalated behaviors on 1/12/2025 and was more difficult to redirect and was disturbing the other residents. CNA E said she had reported to LVN C several behaviors since the start of her shift at 6:00 AM. CNA E said Resident #1 was sitting at the table with her and CNA D and appeared settled at that moment. CNA E said she left the secured unit to retrieve the breakfast trays while CNA D was providing care with another resident. Upon returning to the secured unit, she heard CNA D hollering to get help. CNA E said upon entering resident #2’s room, CNA D was attempting to restrain Resident #1 from going at Resident #2. CNA E said she removed Resident #2 to the commons area at the front of the secured unit. CNA E said she alerted LVN C by the phone located in the commons area of the secured unit to come and assist CNA D. CNA E said they continued to keep Resident #1 from other residents until the EMT arrived to transport Resident #1.

During an interview on 02/26/2025 at 01:15 PM, CNA D said during her shift on 1/12/2025. she noticed Resident #1 was not in the commons area or his room after she finished providing care to another resident. CNA D stated while she looked for Resident #1, she faintly heard Resident #2 call for help. CNA D said when she entered Resident #2’s room, Resident #1 was leaning over Resident #2 with both hands around her neck. CNA D said she had to pry Resident #1’s hands and fingers from Resident #1’s neck. CNA D said she got him down in a sitting position on the floor and placed his hands behind his back as Resident #1 continued to try to go at Resident #2. CNA D stated CNA E arrived back on the secured unit, and she yelled for her. CNA E removed Resident #2 from the room and notified LVN C by the phone located in the commons area of the secured unit. CNA D stated she continued to restrain Resident #1 until the police arrived. LVN C entered the room and then contacted 911. CNA D said the EMTs, and police assisted to transport Resident #1 out of the
building to the hospital.

During an interview on 02/26/2025 at 03:41 PM, the social worker stated she had not worked on a transfer for Resident #1 until 01/15/2025 after Resident #1 had transferred from the facility. The social worker stated she could not recall any conversation or text messages regarding Resident #1 until after he had left from the facility. The social worker stated escalated behaviors were addressed by putting the care plan interventions in place. When those interventions failed, the facility would transfer the resident with escalating behaviors out of the facility to a behavior unit. The social worker defined escalated behaviors as a change from the resident’s baseline behavior such as increased agitation, crawling on floors, no longer able to distract the resident. The social worker said these failures could resulted in harm to residents such as death.

During an interview on 02/26/2025 at 07:11 PM, LVN F said Resident #1’s behavior had changed. LVN F stated Resident #1 could usually be redirected. LVN F stated that she reported to the ADON and the DON on 01/11/2025 that Resident #1 was more difficult to redirect. LVN F stated she was instructed to continue to redirect the resident and give medications as ordered. LVN F stated Resident #1 took off his pants in the commons area which he had never done anything like that before. LVN F stated the CNA reported to her that Resident #1 kicked Resident #3. LVN F stated she failed to complete the incident report and report the incident to the ADON, the DON, or the Administrator. LVN F stated the incident should have been investigated due to being a resident-to-resident altercation. LVN F stated it was at change of shift and although she had reported the incident to the oncoming shift, an incident report should have been completed by her at the time the incident had occurred. LVN F stated the physician should have been notified as well as the families of the residents involved. LVN F stated reporting should be completed for investigation and to protect the residents from abuse.