EULESS, TX- WESTPARK REHABILITATION AND LIVING

Based on observation, interview and record review, the facility failed to provide a safe environment free from  abuse for 4 (Resident #3, #12, #13, and #14) of 14 residents reviewed for abuse.

The facility failed to protect and assure the safety of Residents #3, #12, #13, and #14 when verbal abuse was reported on 10/19/22 and 10/20/22. Resident #3 was verbally abused by staff (recorded on video footage) and Residents #12, #13, and #14 said they were verbally abused by CNA E.

These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish caused by fear.

This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 10/24/22. While the IJ was removed on 10/29/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility’s need to complete in-service training and evaluate the effectiveness of the corrective actions.

In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3’s room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident’s family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3’s family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3’s family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them.

On 10/20/22 at 10:43 AM, a video was received from Resident #3’s responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident’s room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?’, then she said angrily, at the door, you stay there and then shuts the door.

On 10/20/22 at 11:08 AM, a video was received from Resident #3’s responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident’s room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident’s bed and told he resident, I’m going to kick your ass. The resident responds but his response could not be understood on the video.

In a telephone interview on 10/20/22 at 11:25 AM, Resident #3’s responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility’s investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident’s room. She said the resident did not
have a roommate and it was not violating any other resident’s privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was
one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won’t be harmed at the facility.

On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees’ care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. 

In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13’s roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What’s your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM –
10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22.

In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation.

In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3’s responsible party, but not related to the allegations of verbal abuse.