TERRELL, TX - Federal inspectors placed Terrell Healthcare Center under immediate jeopardy status after a resident with severe cognitive impairment repeatedly injured herself over two days while staff failed to implement adequate safety measures or notify physicians.
The March 2025 inspection revealed multiple instances where a resident with schizoaffective disorder and bipolar disorder hit her head against walls and glass doors while staff members watched without effective intervention. The facility also failed to prevent the same resident from smoking cigarettes inside the building twice in one day and leaving the premises unsupervised on multiple occasions.
Pattern of Self-Harm Without Intervention
Inspection records documented seven separate incidents where Resident #45 engaged in self-harming behavior over a 48-hour period. On March 24 at 5:20 PM, the resident was observed hitting her head on a wall near the dining room. An administrator redirected her, but she resumed the behavior immediately after he walked away.
The following day brought four additional incidents. At 8:45 AM, the resident hit her head on a hallway wall while several staff members intervened and redirected her. At 11:21 AM, she was again observed hitting her head on a wall next to the dining room, requiring multiple staff to redirect her. At 2:30 PM, she pulled herself up from her wheelchair at the front entrance and began hitting her head against the glass doors. A dietary supervisor attempted to redirect her, then returned to the kitchen. Just two minutes later, the resident rolled away from the dining room and returned to the glass door, hitting her head against it once more.
According to the facility's psychiatric physician, the dangers associated with repeated head trauma include skull fractures, concussions, and brain hemorrhages. Self-inflicted head injuries can cause immediate tissue damage, intracranial bleeding, and long-term neurological complications. Without proper intervention, repetitive head trauma compounds the risk of permanent brain injury.
The resident's medical record indicated she had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Her diagnoses included schizoaffective disorder, bipolar disorder, hemiplegia affecting the left side, and anxiety disorder. Despite these conditions and documented behavioral issues, facility staff failed to implement adequate protective measures.
Failure to Notify Medical Providers
Perhaps most troubling, the facility did not notify the resident's physician or nurse practitioner about the escalating self-harm behaviors. During interviews on March 25, both the medical director and the nurse practitioner stated they were not informed about any incidents where the resident was found outside the facility or smoking inside.
The medical director confirmed he was not notified the resident was smoking in the facility, nor was he aware of her being found outside the premises. The psychiatric physician who managed the resident's psychotropic medications stated he was unaware of any increased or worsened behaviors until facility staff contacted him on March 25, after surveyor intervention.
Communication with medical providers is fundamental to resident safety, particularly when behavioral changes occur. Psychiatric medications require careful monitoring and adjustment based on observed behaviors. Without accurate, timely information about escalating self-harm, physicians cannot make informed decisions about medication changes or additional interventions that might protect the resident.
Inadequate Care Planning and Documentation
The facility's care plan dated January 15, 2025, acknowledged the resident had a behavior problem that included "banging her head against the wall when she became frustrated." However, the interventions listed were limited to monitoring behavior episodes, attempting to determine underlying causes, and documenting behavior and potential causes. The care plan was not revised until March 26, after surveyor intervention, to include one-on-one observation.
Medical records showed significant documentation failures. The resident's medication administration record indicated zero documented behaviors three times daily from March 1-25, despite her receiving Seroquel 200mg three times daily for mood and behavioral symptoms. This documentation suggested she had no behavioral episodes during the entire month, contradicting the observations of repeated self-harm.
Accurate documentation serves multiple critical functions in skilled nursing facilities. It ensures continuity of care across shifts, provides physicians with essential information for treatment decisions, and creates a record that staff can review to identify patterns and triggers. When documentation fails to reflect reality, residents lose the protective benefits of coordinated, informed care.
Smoking Safety Violations
The same resident was found smoking inside the facility on two occasions March 25. At 8:38 AM, a nurse discovered the resident smoking indoors. Following facility smoking protocol, staff confiscated her cigarettes and vape, which angered the resident and led to her banging her head on the wall, cursing at staff, and yelling.
Despite this incident and a reassessment that deemed her an unsafe smoker requiring supervision, the resident was found at 12:57 PM that same day smoking a lit cigarette in the hallway while coming from the back hall to the smoking area.
Indoor smoking in healthcare facilities creates multiple hazards beyond fire risk. For residents receiving supplemental oxygen or with respiratory conditions, exposure to smoke and secondhand smoke can cause immediate breathing difficulties. The resident herself had been admitted with a history of stroke affecting her left side, making her mobility limited and potentially compromising her ability to respond quickly in an emergency.
Elopement Incidents
Inspection records revealed the facility failed to prevent the resident from leaving the premises on multiple occasions. On February 25 at approximately 6:00 PM, the resident left the facility unnoticed. She was last seen around the end of supper. Staff found her at approximately 6:30 PM, located 0.2 miles (1,056 feet) from the facility beside a bank next to a main highway.
Just two days later on February 27, the resident again left the facility. She was supposed to be on 15-minute monitoring checks but managed to leave and was found on the left side of the building by a busy road.
The Director of Nursing acknowledged that an elopement assessment should have been completed on admission and quarterly, and that the resident should have been reassessed when she was noted at risk. However, record review revealed no wandering or elopement assessments were completed prior to surveyor intervention on March 25.
A wander guard device was ordered on March 1, but nursing staff reported the resident "threw a tantrum" to have it removed. Despite the resident's severe cognitive impairment and documented elopement risk, the facility did not implement alternative safety measures or reassess her needs.
Staff Knowledge Gaps
Interviews with staff revealed significant gaps in understanding of policies and procedures. One nurse stated she accidentally input the wrong time when documenting finding the resident smoking in the lobby. When asked about the resident's smoking history, the nurse said the resident had never smoked in the facility before but had always kept cigarettes on her person.
The charge nurse responsible for the resident on the dates she left the facility stated she notified the administrator, who instructed her to place the resident on 15-minute checks. However, this intervention proved inadequate, as the resident was able to leave again just two days later while supposedly on 15-minute monitoring.
Additional Care Violations
Beyond the immediate jeopardy findings, inspectors identified multiple additional violations affecting resident care and safety:
A resident with diabetes had long, thick, yellow fingernails with yellow-tinged matter underneath them. Despite being bathed multiple times over three weeks, documentation showed nail care was never provided. The resident stated he would like his nails trimmed and did not like them long. Facility policy required nail care to be performed during baths, with nurses responsible for trimming diabetic residents' nails.
Another resident with an indwelling catheter did not receive ordered catheter care on multiple shifts in March. A different resident requiring daily wound care had treatment documented on the nurse's dressing dated March 16, but it was not changed on the expected date of March 23, creating infection risk.
Immediate Jeopardy Removal
The facility implemented a plan of removal on March 26. Immediate actions included placing the resident on one-on-one supervision, securing her smoking materials under staff control, completing a smoking assessment that required supervision when smoking, and notifying the physician of behaviors.
Staff received in-service training on abuse and neglect, accident and hazard supervision, smoking safety, elopement protocols, and behavioral health services. The facility updated care plans, completed risk assessments, and established monitoring procedures including weekly life safety rounds.
Federal surveyors confirmed the immediate jeopardy was removed on March 28 after verifying staff education, updated assessments and care plans, and implementation of one-on-one observation. However, the facility remained out of compliance and required continued monitoring to evaluate the effectiveness of corrective measures.
Medical Standards for Behavioral Health
Professional standards require nursing facilities to provide necessary behavioral health care and services to help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. This involves an interdisciplinary approach with qualified staff demonstrating the competencies and skills necessary to provide appropriate services.
Individualized care approaches should be directed toward understanding, preventing, relieving, or accommodating a resident's distress or loss of abilities. When residents exhibit behavioral symptoms, facilities must rule out underlying causes through proper assessment and diagnosis, implement non-pharmacological approaches based on comprehensive assessment and care plans, and monitor ongoing effectiveness of interventions.
The violations at Terrell Healthcare Center represent failures at multiple points in this care continuum - from initial assessment and care planning, to staff implementation of interventions, to communication with medical providers, to monitoring and revision of care approaches.
For residents and families considering placement options, these inspection findings highlight the importance of reviewing recent survey results, asking specific questions about staffing ratios and supervision protocols, and maintaining regular contact with loved ones in care facilities.
The full inspection report is available through the Centers for Medicare & Medicaid Services Nursing Home Compare website for those seeking additional details about deficiencies and facility responses.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrell Healthcare Center from 2025-03-29 including all violations, facility responses, and corrective action plans.
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