Thank You Nurses - Dallas

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure 1 of 1 of the agency’s patients (Patient #2) was free from abuse by an agency employee in that: 1) Patient #2 stated that PROV A gave Patient #2 gummy candies laced with marijuana (a candy containing an ingredient which produces mind altering effects) a total of 3 to 4 times. This failure placed Patient #2 in harm and was hospitalized. Findings included: During a home visit to Patient #2 on 6/11/2026 at 11:00 a.m., Patient #2 stated that PROV A was assigned to Patient #2 since 11/19/2025 for personal attendant services. Patient #2 and FM A present for interview. Patient #2 stated that during the winter storm in late January and February in 2026, Patient #2 was unable to get a refill of her pain medication. Patient #2 stated that FM A usually assists in medication management. Patient #2 stated that PROV A offered her an herbal oral alternative for her pain and restlessness. Patient #2 stated that she thought it was natural like tea as she is familiar with herbal remedies like Chamomile tea. Patient #2 stated that the herbal remedy tasted like candy and took her pain away, but it made her feel like she was floating. Patient #2 stated that it made her very hungry after an hour or so after taking the herbal remedy. Patient #2 stated that PROV A gave her herbal remedy about three or four times. Patient #2 stated that, “I don’t use drugs and never have.” FM A stated that she was unaware that PROV A was giving Patient #2 marijuana laced candy until Patient #2 was hospitalized on 2/10/2026-2/17/2026 for brain disease due to marijuana use. FM A further stated that PROV A informed FM A that she gave Patient #2 marijuana gummies. FM A also stated that PROV A found Patient #2 unresponsive and foaming from the mouth. FM A stated that PROV A called her first before calling 911 to inform her of Patient #2’s status stated, “The [expletive] better not die on me.” FM A stated that she had to tell PROV A to call 911. FM A further stated that Patient #2 stated that she had no idea that the candies contained marijuana until she was hospitalized. Patient #2 stated that her rights were not protected as a Patient of the agency. During a record review of Patient #2’s PAS individual service plan revealed a start of care date of 11/19/2025 with a diagnosis of rheumatoid arthritis (a condition that causes pain as the body attacks the joints in the bones). Further review of the Patient #2’s PAS individual service plan further reveal PROV A was assigned to Patient #2 for 44 hours weekly, 7 days per week. For bathing, dressing and toileting. Further record review revealed PAS individual service the duty of self-medication assist checkbox was unchecked. During a record review of Patient #2’s hospital records reveal that Patient #2 was hospitalized between 2/10/2026-2/17/2026 with a diagnosis of altered mental status. Further record review of Patient #2’s urine drug screening, dated 2/10/2026, revealed that Patient #2 was positive (contains) for marijuana or herbals. During a record review of PROV A employee records revealed a date of hire of 11/19/2025 with an EMR/NAR search conducted on 11/17/2025. PROV A training records dated 11/19/2025, reveal that PROV was oriented on 911 procedures and ANE with the requirement to report ANE. Review of the agency’s incident record in TULIP, dated 2/20/2026, revealed that agency learned of the incident on 2/20/2026. Three attempts to contact PROV A on 6/10/2026 ( 1:00 pm 1:05 pm) and 6/14/2026 at 1:00 p.m. were unsuccessful. During a record review of PROV A witness statement dated 2/26/2026, revealed that PROV A denied the allegation of PROV A gave Patient #2 marijuana laced gummies. During joint interview with the Alternate Administrator and Administrator on, the 6/12/2026 at 2:00 p.m., the Alternate Administrator and Administrator were informed of the above findings. The Administrator stated that all attendants are instructed on ANE and the specific tasks that they are required to perform. The Administrator further revealed that PROV A was not instructed on medication administration assistance. The Administrator stated that it is important for the agency to adhere to Patient rights. The Administrator further revealed that she was not aware of PROV The Administrator stated that the agency conducted an internal investigation. The Administrator stated that she was not aware that PROV A giving Patient #2 marijuana gummies until after Patient #2 was hospitalized to which she reported the incident to the State immediately. The Administrator also stated that the agency staff are educated on ANE. Review of the agency’s policy, dated 1/2024, titled “Patient’s Rights and Responsibilities,” revealed in part, “1.The Patient…will be informed at admission and on an ongoing basis, as needed, of their rights and responsibilities, which include the rights to…Have his or her property and person treated with respect, consideration, and recognition of Patient dignity and individuality…Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of Patient property…””