HOUSTON, TX- SPRING BRANCH TRANSITIONAL CARE CENTER

Based on interview and record review the facility failed to have evidence that all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated for 1 of 14 residents reviewed for abuse and neglect (CR #181), in that:
– HA C admitted to taking wheelchair bound resident’s, CR #181, call light from his pillowcase and placing it out of reach after the resident pressed it multiple times.
– CR #181’s hospital record documented resident refused to return to the facility because he believed he was abused by staff.
– The Administrator failed to obtain documented statements from LVN J and HA C.
– The Administrator failed to thoroughly review CR #181’s hospital records and LVN J’s nurses notes and address the allegation that resident’s call light was taken away.

This failure caused one resident to experience feelings of fear from abuse and placed all residents at risk of not having instances of abused addressed and thoroughly investigated.

Findings included:
Record review of CR #181’s face sheet revealed a [AGE] year-old male resident who admitted from a hospital. No diagnoses were listed.

Record review of CR #181’s nurses notes, dated 01/19/2023 at 3PM, revealed the resident, . admitted to the facility from [Hospital] at 1:30PM via stretcher .

Record review of CR #181’s nurses notes, dated 01/19/2023 at 11:15PM, LVN J wrote Resident [complaint of] left shoulder pain p being assaulted by staff that snatched call light away from him fracturing his arm or shoulder causing mark on his left arm. Resident refused nurse to complete skin assessment. Nurse observed to BUE scabbed over areas. Resident requested to notify 911 as he wanted to speak [with] police to file assault charges [and] that he can not stay here again. Nurse asked to assess him [and] refused stating that he was not doing a dog [and] pony show for me [and] would not do anything for me.

Record review of CR #181’s nurses notes, dated 01/19/2023 at 11:50PM, LVN J wrote, Resident observed [with] EMT performing ROM to BUE. No signs or symptoms noted of any pain, distress or discomfort during their assessment of the resident. EMT cleared resident in house stating they don’t feel that he is needed to go to the ER. As vital signs were good [and] ROM performed effectively. Resident requested to go to hospital to be further evaluated stated chest pain. Resident was transported from facility to ER [with] no marks or bruising noted during EMT’s assessment prior to transfer. RP [family member] notified of above. Record review of CR #181’s skin assessment, dated 01/19/2023, noted old scab on left and right lower arms.

Record review of CR #181 Hospital records, dated 01/20/2023, revealed the resident was a [AGE] year-old patient with, .history of coronary artery disease pacemaker, left hip and right knee replacement who is bedbound and does not ambulate and has been in multiple’s SNF facility who had presented to the emergency room initially on 01/21/2022 with complaints of left shoulder pain after EMS had been called for patient to complain that he had been assaulted as she had nursing call bell wrapped around his left forearm and was subsequently pulled by the staff for which he suffered bruising and a tendon laceration. He has been evaluated in the emergency room and and have been subsequently discharged from the emergency room but patient refuses to leave the emergency department to go back to the nursing facility because believes he has been abused [sic] . The hospital record revealed the chief complaint at the ER was of, . Left shoulder pain after call light cord being ripped out from [under] him/ [patient] does report chest pain as well.
Bruise and skin tear to [left] arm . CR #181’s x-ray result findings revealed, .near complete loss of the subacromial space, consistent chronic rotator tear, similar prior exam [performed 01/21/2022]. Mild-to-moderate degenerative arthritic changes of the acromioclavicular . no acute fracture . In the Medical Screening Exam notes, it stated, . [AGE] year-old male . complaining of left shoulder pain after arguing with the nurse at a nursing facility when hurt his left shoulder and stated that he felt like it came out of joint and popped back in. Patient characterizes pain at an 8 out of 10 with a throbbing sensation .

Phone interview with CR #181 was attempted on 3/21/2023 at 10:30AM but surveyor was unsuccessful in reaching the resident.

Record review of Corrective Active Form signed 01/19/2023, revealed HA C’s discharge date was
01/19/2023 and stated, employee suspended, pending investigation of resident rights. The form was signed by the Administrator and Human Resource Staff.

In an interview with HA C on 03/21/2023 at 3:45PM, he stated his role as a hospitality aide was to monitor the residents, answer call lights and take them out for smoke breaks. He stated he went to answer CR #181’s call light, after he had already pressed it seven times, and asked if he needed anything. He said CR #181 called him names, such as nig*** faggot and in response, he snatched CR #181’s call light that was clipped to the resident’s pillow and placed it out of reach on the table, to prevent the resident from pressing the call light again. HA C stated he did so because he felt insulted by what the resident said to him. He stated the call light was never attached to the resident’s body and that he never touched CR #181 but the resident lied to LVN J and said I punched him and broke his arm. HA C stated LVN J made him write a report on the incident and he went home because his shift was over soon after the incident. HA C stated he was not suspended as a result of the incident.

In a follow up interview with HA C on 03/22/2023 at 2:33PM, HA C said the Administrator told him to stay home the next day after the incident and he did not return until a total of 3 days later, which was the next time he was scheduled to work again. He stated he was never given the Corrective Active Form, dated 01/19/2023, and he did not know it existed. dated HA C said he took the call light from CR #181 and did not return it to him prior to leaving the room. HA C stated did not know that taking the call light was a human rights issue because the resident was being aggressive and continued to click the call light button. HA C said LVN J came into the room and asked if he took the call light away and he admitted he did and was told by LVN J that it was a form of abuse. HA C said he was trained on abuse during new hire orientation and when
he returned to work, the Administrator, the ADON and the Human Resource staff pulled him aside one by one to tell him what he did was wrong.

Record review of personnel records revealed HA C received training on abuse upon hire on 06/30/2022. After request for training documents were made on 03/22/2023 at 2:00PM, no other records of abuse training for HA C after the incident on 01/19/2023 were provided prior to exit.

In an interview with LVN J on 03/22/2023 at 12:20PM, LVN J said at the time of the incident, she was the night supervisor who was called forth by an unknown staff member to tend to CR #181. She stated she kept the alleged perpetrator, HA C, out of the room while she attempted to assess the resident. The resident accused HA C for breaking his arm but refused LVN J’s assessment further for range of motion and bruising and told her he was fine She said CR #181 also wanted to call the police and press charges on HA C but the police never showed up during her shift. She stated she called and reported the incident to the Administrator who told her to send HA C home and that he would take care of the incident. LVN J said she considered the
incident as abuse which is why she notified the abuse coordinator.

In a follow up interview with LVN J on 03/25/2023 at 8:50AM, she stated she did not witness the incident but was called down to see what CR #181’s allegations were. LVN J stated she considered what HA C did with the call light maybe abuse, but more so neglect because the call light is his lifeline and he needs it for communication. She stated she reported to the Administrator over the phone that CR #181 was accusing HA C of breaking his arm but could not remember if the call light was mentioned in the conversation at that time. She stated before this incident happened, she was unsure if she was taught whether taking a call light from a resident was considered as abuse, neglect or resident rights.

In an interview with the Administrator on 03/23/2023 at 3:09PM, the Administrator stated he was the abuse coordinator. He stated on the night of 01/19/2023, LVN J called him and informed him of the incident: that CR #181 was a new admission who was being out of control, who wanted to leave the facility and made accusations against HA C for breaking his arm. The Administrator said LVN J told him CR #181 did not allow her to assess him for bruising, but from what she could see, she did not see any obvious bruising. The Administrator stated he thought the investigation was very cut and dry with the main allegation being his arm was broken. He stated he reviewed the hospital records and looked at the x-ray results for CR #181’s arm which revealed there was no broken arm. The Administrator stated he never heard about the call light being taken away until surveyors started questioning about it today. He said he was not sure if taking the call light was a resident rights issue or abuse issue because he would need to ask HA C what he did and why he did it, but he and LVN J both did not believe HA C would hurt the resident.

In an interview with 3/22/2023 at 3:53PM, the administrator stated he could not find any written statements from staff related to that incident and he could not find any inservice trainings related to abuse that was given HA C.

In a follow-up interview with the Administrator on 03/23/2023 at 2:00PM, the Administrator stated he, himself, was responsible for conducting the investigation on the allegations made by CR #181 and the purpose of investigations were to find the most probable cause of the issue or to rule out mistreatment. The Administrator explained he had phone call conversations with LVN J and HA C the night of the incident, the following morning, he sent out the Facility Marketer to obtain CR #81’s records indicating him arm was not broken, and hospital staff interviews, in which the case manager reported the hospital staff were very familiar with CR #181, who had a pattern of behaviors and making false accusations to leave facilities. He stated from that information, he assumed CR #181 knew what to say to get out of facility right away. He stated during investigations, he did not get statements from the staff that worked at the time of the incident or those involved, but he instead gathered a random sample of staff from all departments, asking if they knew what happened to CR #181. He stated if the alleged perpetrator returned to work, it is because they had been deemed to be safe enough to return, or else, they are terminated or suspended for however long until they were deemed safe, and the alleged perpetrator would have a documented one-on-one inservice with them as well. He stated he deemed HA C safe enough to work because the x-rays showed CR#181 did not acquire a broken arm as he alleged and because HA C stated he never touched the resident. The Administrator said at the time, he thought he did a thorough investigation on the CR #181’s allegations with focus on the broken arm. He stated he did not know exactly what the abuse policy stated about investigations and today was his first time he read through the investigation instructions listed in the facility policy on Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating. He stated after reading through the policy, that he did not follow it while investigating this incident.

Record review of forms titled, [Facility Name], revealed 22 staff members were asked to document the seven types of abuse, including involuntary seclusion, who to contact if abuse is witnessed or alleged, and if they knew what happened to CR #181. Of the 22 staff members, HA C was not included.

Record review of the facility’s policy on Abuse Prohibition Standards of Practice, dated 11/1/2016, stated, . Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. The following standards of practice will be operationalized in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff .

Record review of the facility’s policy on Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated April 2021, stated, . 1. All investigations are thoroughly investigated. The administrator initiates investigations . 3. The administrator provides supporting documents and evident related to the alleged incident to the individual in charge of the investigation . 7. The individual conducting the investigation as a minimum: a) reviews the documentation and evidence; b) reviews the resident’s medical record to determine the resident’s physical and cognitive status at the time of the incident and since the incident; . d) interviews the person (s) reporting the incident; e) interviews any witness to the incident; f) interviews the
resident (as medically appropriate) . h) interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; . j) interviews other residents to whom the accused employee provides care or services; k) reviews all events leading up to the alleged incident; and l) documents the investigation completely and thoroughly . 8. d) witness statements are obtained in writing, signed and dated. The witness may write his/her statement or the investigator may obtain a statement . The policy also stated corrective actions included, . If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) is terminated . 4) If the allegation reveals that the allegation(s) of abuse are unfounded, the employee(s) may be reinstated to her/her/their/ former position .