Retama Manor Faces Immediate Jeopardy for Resident Abuse Investigation
PLEASANTON, TX - Retama Manor Nursing Center faced immediate jeopardy violations following a federal investigation into allegations of resident abuse that occurred during a care incident in March 2024.
The incident involved an elderly male resident with Lewy body dementia who sustained multiple skin tears and a possible fracture to his left hand during what staff described as a combative care episode on March 28, 2024.
Details of the Care Incident
According to the federal inspection report, the resident became combative during incontinence care provided by a certified nursing assistant (CNA). The CNA reported that the resident "got out of the bed, grabbed her scrub top, ripped her top, and pulled her hair" during the care episode.
Despite the resident's resistance, the CNA continued providing care without calling for assistance. The facility's care plan specifically required two CNAs to assist this resident at all times due to his history of combative behavior.
The resident sustained multiple injuries during the incident, including skin tears to his right forearm, left hand, and left fourth finger, along with swelling to his right hand. X-rays revealed no acute fractures to the right hand but showed degenerative arthritis.
Escalating Medical Concerns
Several days later, on April 2, 2024, the resident developed new swelling and bruising to his left hand. A subsequent X-ray showed "distal radial diametaphyseal irregularity" with findings that could not rule out a fracture. The attending nurse practitioner diagnosed possible cellulitis and ordered antibiotic treatment.
Medical records documented progressive symptoms including bilateral upper extremity discoloration and continued swelling. The resident was ultimately fitted with a hand splint for stabilization.
Facility's Investigation Response
The Director of Nursing stated she became aware of the incident on March 29, the morning after it occurred. The facility interviewed the CNA by phone on April 3, where she reported that the resident "was combative during care and beat her up."
According to the investigation, the CNA acknowledged she should have called for help to ensure both resident and staff safety. However, she stated she "usually could get them to calm down on her own" and continued care because "he was naked."
The facility initially treated the incident as an injury of unknown origin rather than potential abuse, citing the resident's history of arthritis and combative behavior. A police report was filed on April 2, though the Director of Nursing stated she "could not confirm if an assault occurred."
Care Plan Violations
The resident's care plan, updated in April 2024, specifically outlined his behavioral challenges and required interventions. The plan noted he "can become combative with care at times" and mandated that two CNAs assist him at all times.
Additional care plan requirements included: - Analyzing triggers and circumstances that escalate behavior - Providing verbal cues to alleviate anxiety - Modifying the environment to reduce stimulation - Stopping and returning if the resident became agitated
The facility's own policies required staff to "just stop care if a resident became combative," according to the Director of Nursing's statement.
Medical Implications of Dementia Care
Lewy body dementia significantly impacts a person's ability to process and respond to care activities. The condition affects brain chemicals responsible for thinking, movement, and behavior, making residents particularly vulnerable during care transitions.
Residents with this form of dementia often experience confusion and fear during personal care activities, especially when they cannot understand what staff are attempting to do. The condition also increases fall risk and injury susceptibility due to movement difficulties and cognitive impairment.
Proper dementia care protocols emphasize the importance of consistent staffing, clear communication, and immediate de-escalation when residents show distress. Continuing care during combative episodes contradicts established best practices for dementia care.
Regulatory Violations and Standards
The incident violated federal nursing home regulations requiring facilities to protect residents from abuse and ensure proper care protocols. Texas regulations mandate that abuse incidents be reported within two hours of occurrence or suspicion.
The facility's failure to immediately report the incident as potential abuse, despite the resident's multiple injuries, represented a significant violation of protective protocols. Additionally, allowing the CNA to continue caring for the resident without suspension pending investigation violated standard investigative procedures.
Immediate Jeopardy Determination
Federal surveyors determined the facility's response constituted immediate jeopardy to resident health and safety on June 5, 2024. This designation indicates conditions that could cause serious injury, harm, impairment, or death to residents.
The facility was required to submit a plan of removal to address the immediate jeopardy findings. The investigation found systemic failures in incident response, staff training, and abuse prevention protocols.
Industry Standards for Dementia Care
Standard dementia care protocols require specialized training for staff working with cognitively impaired residents. This includes techniques for de-escalation, proper positioning during care, and recognition of behavioral triggers.
Facilities must maintain adequate staffing ratios for residents with behavioral challenges and ensure staff receive ongoing education about dementia-related behaviors. When residents become combative, the standard response is to pause care, ensure safety, and reassess the approach rather than continue despite resistance.
Ongoing Investigation
The incident remains under investigation by state regulators and local law enforcement. The facility submitted corrective action plans addressing staff training, incident reporting procedures, and care plan compliance.
Federal surveyors noted that several key staff members involved in the incident were unavailable for interviews during the investigation, including the LVN who initially documented the resident's injuries.
The case highlights the critical importance of proper protocols when caring for vulnerable residents with cognitive impairments and the potential consequences when facilities fail to prioritize resident safety over care completion.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Retama Manor Nursing Center/pleasanton North from 2024-06-07 including all violations, facility responses, and corrective action plans.
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