PALESTINE, TX- PALESTINE HEALTHCARE CENTER

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

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

Based on interviews, observation and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 7 of 12 (Resident #’s 2, 3, 4, 5, 6, 7, and 8) residents reviewed for abuse, neglect, and misappropriation of property.

1.The facility did not implement their policies and procedures related to interventions for resident-to-resident altercations after Resident #1 hit Resident #2 twice on the arm. Resident #1 then hit and spit on Resident #3, 30 minutes later.

An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:37 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because (e.g.) all staff had not been trained on Abuse/Neglect, Resident-to-Resident Altercations, and 1:1 monitoring of the aggressors.

2.The facility did not implement their policies and procedures related to investigation and reporting allegations of misappropriation of property when Activity Director A:
* took money via cash app from Resident #4 in the amount of $1,150.00 dollars;
* took cash money from Resident #5 in the amount of $100.00 dollars.
* attempted to take cash money from Resident #6 in the amount of $100.00 dollars.
* took cash money from Resident #7 in the amount of $25.00 dollars.
* took cash money from Resident #8 in the amount of $20.00 dollars.

This failure could place residents at risk for abuse, neglect, misappropriation of property, and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being.

During an interview and observation on [DATE] beginning at 10:38 AM CNA D observed about to exit the secured unit. She said LVN N had told her she no longer had to do 1:1 monitoring with Resident #1. She said Resident #1 rolled into the dining room on Sunday [DATE] at 04:45 PM and hit Resident #2 twice on the right arm. She said Resident #1 and Resident #2 were immediately separated. She said a little while later Resident #1 rolled up to Resident #3 in the hallway of the secured unit and hit and spit on Resident #3. She said sometime after the second incident Resident #1 was put on 1:1 monitoring. She said she came in at 06:00 AM this morning on [DATE] and was told she no longer had to do 1:1 monitoring with Resident #1 so she was going to ask the ADON.

During an interview on [DATE] at 10:50 AM CNA O said she works for an agency and had Been coming to this facility for about 3 weeks. She said she works All over the building and that was her 2nd day on the secured unit. She said there is always 2 CNAs on the unit. She said she had not received any in-services or training before working on the secured unit. She said yesterday [DATE] Resident #1 hit and spit on 2 residents. Said she was on the war path, and she went over and hit Resident #2 on the shoulder twice then went over to Resident #3 and hit him and spit on him. She said Resident #1 then sat at the table and cussed everyone out. She said on [DATE] her behavior was horrible, but that was her behavior sometimes. She said she reported to her charge nurse and wrote out witness statements. She said that is the only altercation she had witnessed.

During an interview on [DATE] at 11:08 AM LVN N Said Resident #1 has sun downers in the evenings and said Resident #1 hit Resident #2 twice on the right arm and then went back and hit Resident #3 and spit on him in the hallway. She said Resident #1 gets very delusional in the evenings but has never hit anyone before [DATE]. She said the ADON asked her what Resident #1 was doing that morning, she said she was asleep. She said the ADON told her to take Resident #1 off 1:1 monitoring that morning since Resident #1 was not having any behaviors. Then the ADON told the CNA to keep Resident #1 on 1:1. She said the ADON came back and told her since state was in the building to go ahead and keep Resident #1 on 1:1 monitoring. She said she did not know if the situation has been reported to the administrator. She said she had received in-servicing over the last several weeks regarding resident-to-resident altercations. She said 2 CNAs were to be on the secured unit at all times.

During an interview on [DATE] at 11:20 AM the DON said she was notified that Resident #1 had hit Resident #2 and spit on Resident #3. She said this behavior is out of the normal for Resident #1. She said she was called and told of the incident but was not in the building at the time. She said she assumed Resident #1 was put on 1:1 immediately.

During an interview on [DATE] at 11:33 AM the ADON said she was called by the 6p-6a nurse and told of the incident and instructed the nurse to put Resident #1 on 1:1 monitoring on [DATE] at 06:16 PM. She said there was some confusion and she had told LVN N they would discuss taking resident off of 1:1 on the morning of [DATE].

During an interview on [DATE] at 1:30 PM the Current Administrator She said she had been notified on Sunday [DATE] by the DON that Resident #1 had hit 2 residents on the secured unit. She said she did not feel like there was willful intent due to Resident #1’s cognition, so she did not feel like she had to report it as abuse.

The facility Administrator was notified on [DATE] at 05:37 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time.

During an interview and observation on [DATE] beginning at 08:40 AM, Resident #7 said she gave Activity Director A 25.00 dollars for some new socks and shoes. Resident #7 said she had not received the socks and shoes or her 25.00 dollars.

During an interview on [DATE] at 08:48 AM the Regional Accounts Manager said in June of 2022 Resident #4 made a $300 dollar payment to the facility and that Activity Director A was able to go and talk the resident in to making. She said Resident did make another 500-dollar payment on [DATE] using his atm card. She said the process for staff going to the store for residents is they are to bring a receipt back and sign a form with the resident stating the resident had received the requested items and change from there purchase. She said under no circumstances are any staff allowed to withdraw any money from a resident’s bank account using there debit card.

During an interview on [DATE] at 09:10 AM with Resident #4 via phone, he said he had given Activity Director A 1,150.00 dollar via cash app, and Activity Director A had taken his ATM card and withdrew an additional 1000.00 dollars from his bank account. Resident #4 said Activity Director A had agreed to take care of him while he was at the nursing facility if he paid her. He said the agreement was he would pay her 50.00 to 100.00 dollars every couple of weeks, and she would make sure he was cared for. He said Activity Director A had given him Activity Director A’s personal cell phone number to call her when he needed care. He said if Activity Director A was at work and he needed care he would call her cell phone and she would come and provide care, if she was not at work then he would call her, and she would call the facility and have someone go to his room to provide the care. He said Activity Director A would occasionally go to the store for him, but all of those purchases were made with Resident #4’s debit card and never with cash app. He said Activity Director A would occasionally ask to borrow money from him that was never paid back. He said most of the time when he needed something from the store, he would order it online and have it delivered to the facility. He said he discharged from the facility on [DATE] and received a call from Activity Director A in [DATE], he said she told him that he still owed her 100.00 dollars for taking care of him, so he sent her 100.00 dollars on [DATE] via cash app. Resident #4 said he does not feel like it was right and now wants his money back.

During an interview on [DATE] at 9:50 AM the BOM said they have a process they started in August of 2022 they are supposed to follow when going to the store for residents due to multiple complaints of residents not getting there change or items. She said there was a form that was to be filled out, and the employee was supposed to bring the receipt back with the items purchased and the change. She said the resident and the employee are supposed to sign the form stating the resident received the items and change from the transaction. She said that Resident #6 came to her in February of 2023 and wanted to withdrawal 100.00 dollars from her trust fund, which was out of the normal for her, so it made her suspicious. She said Resident #6 took the money to the social worker/activity director A office and Activity Director A was not there so the resident gave the money to the SW and asked him to give it to the Activity Director A. The SW intercepted the money and took it back to the business office. She said her Regional Account Manager came to the facility and did an investigation at that time, but the resident would not talk to the Regional Account Manager. The money was replaced in Resident #6’s trust fund. She said she witnessed Resident #5 withdraw 100.00 dollars on [DATE] and give the money to Activity Director A to go buy him cigarettes and a pair of shoes, but Resident #5 has never received the shoes or the cigarettes. She said Resident #5 was one of her residents she checks on daily, so she has been checking daily to see if Resident #5 had ever received a new pair of shoes but had not at that time. She said Resident #7 has been complaining that she gave Activity Director A 25.00 dollars for some shoes and socks, and the resident has not received the shoes or socks. She said Resident #8 had also complained that she had given Activity Director A 60.00 dollars for snuff and that she had not received any change. The BOM said she had reported to the Previous Administrator that Activity Director A would not fill out the form for resident shopping or bring receipts back, she said she had also reported to the Current Administrator about a week ago that Resident #5 had not received his items from Activity Director A since [DATE].

During an interview and observation on [DATE] at beginning 10:30 AM Resident #5 said when asked if Resident #5 gave Activity Director A 100.00 dollars he said yes. When asked if Resident #5 had received any shoes for Activity Director A he said no.

During an interview and observation on [DATE] at beginning 10:38 AM Resident #6 said she did not want to say anything about Activity Director A.

During an interview on [DATE] at 11:00 AM the Assistant Activity Director said she doesn’t believe Activity Director A was getting what the residents want when shopping. She said she doesn’t get the cigarettes the resident smokes that she will buy the cheap stuff so that it costs less and then keep the change. She said the residents just takes whatever she gets them. She said there has been assumptions for a long time that she buys the cheap stuff and pockets the change. She said she can see that was what Activity Director A had been doing. She said she was not supposed to take money from the residents it was supposed to come from the BOM. She said she has never seen anyone use cash app. She said Resident #7 told her she gave Activity Director A money for socks and shoes and Resident #7 said she had never received her stuff.