PALESTINE, TX- PALESTINE 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** 

Based on observation, interview and record review the facility failed to ensure residents were free
from abuse for 2 of 5 residents (Resident #1 and Resident #3) reviewed for Resident Abuse.

1. The facility failed to protect Resident #1 from abuse by Resident #2. On 04/05/2023 Resident #1
wandered into Resident #2’s room on the secured unit, and Resident #2 threw water on Resident #1 and then grabbed Resident #1 causing a skin tear to Resident #1’s right mid arm.

2. The facility failed to protect Resident #3 from abuse by Resident #2. On 04/15/2023 Resident #2 stabbed Resident #3 with a pen causing a puncture wound to Resident #3’s left forearm.

3. The facility failed to protect Resident #3 from abuse by Resident #2. On 05/25/2023 Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor.

An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on
[DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult.

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

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

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

Based on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 2 of 5 (Resident #1 and Resident #3) of residents reviewed for incidents.

The facility failed to ensure the residents right to be free from abuse, neglect, misappropriation,
of resident property and exploitation.

The facility failed to implement their policy by not consulting psychiatric services for resident-to-resident altercations after Resident #2 threw water on and then grabbed Resident #1 causing a skin tear to Resident #1’s arm.

The facility failed to implement their policy by not consulting psychiatric services for resident-to-resident altercations after Resident #2 Stabbed Resident #3 in the arm with a pen.

The facility failed to implement their policy by not consulting psychiatric services for resident-to-resident altercations after Resident #2 pushed Resident #3 out of her wheelchair and onto the floor.

An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on
[DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult.

These deficient practices could affect any resident and contribute to further abuse.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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

Based on observation, interview, and record review the facility failed to ensure adequate
supervision was provided to prevent accidents for 3 of 5 residents reviewed for accidents and
supervision. (Resident #1, Resident #2, and Resident #3)

1. The facility failed to adequately provide supervision for Resident #1 and Resident #2. On
04/05/2023 Resident #1 wandered into Resident #2’s room on the secured unit, and Resident #2 threw water on Resident #1 and then grabbed Resident #1 causing a skin tear to Resident #1’s right mid arm.

2. The facility failed to adequately provide supervision for Resident #2 and Resident #3. On
04/15/2023 Resident #2 stabbed Resident #3 with a pen causing a puncture wound to Resident #3’s left forearm.

3. The facility failed to adequately provide supervision for Resident #2 and Resident #3. On
05/25/2023 Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor.

An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on
[DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult.

This failure placed all residents in the secured unit at risk of injury and death.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 

Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being 1 of 3 resident (Resident #2) reviewed for behavioral health.

1. The facility failed to assess and implement interventions on 3 separate occasions when Resident
#2 had behaviors of aggression. On 04/05/2023 Resident #1 wandered into Resident #2’s room on the secured unit, and Resident #2 threw water on Resident #1 and then grabbed Resident #1 causing a skin tear to Resident #1’s right mid arm.

2. The facility failed to assess and implement interventions on 3 separate occasions when Resident #2 had behaviors of aggression. On 04/15/2023 Resident #2 stabbed Resident #3 with a pen causing a puncture wound to Resident #3’s left forearm.

3. The facility failed to assess and implement interventions on 3 separate occasions when Resident
#2 had behaviors of aggression. On 05/25/2023 Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor.

The facility failed to immediately provide psychological services for Resident #2 following 3
separate residents to resident altercations on 04/05/2023, 04/15/2023 and 05/25/2023. On 02/28/2023 an order for a psych consult was written for Resident #2 to be evaluated and treated. Resident #2 was not evaluated until 06/08/2023 by psychological services.

An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on
[DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of isolated and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult.

These failures affected residents living in the facility at risk of not receiving behavioral health
services, increased anger and behaviors, inflicting harm on others, anxiety and decline in quality of life.