F0609

D

Failure to Timely Report Alleged Neglect and Poor Incontinence Care

Ballinger, Texas Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an allegation of neglect involving Resident #1 to the State Reporting Agency (HHSC) within 24 hours, as required by regulation and the facility’s abuse/neglect policy. Resident #1 was an elderly male with unspecified dementia, unspecified convulsions, and COPD, who had a terminal prognosis, was on hospice for adult failure to thrive and senile degeneration of the brain, and had severe cognitive impairment with a BIMS score of 00. He was always incontinent of bowel and bladder and required substantial to maximum assistance for bed mobility and extensive assistance of two staff for toileting, with a care plan intervention for incontinence care every two hours.

On 12/26/2025, multiple staff observed Resident #1 in a soiled and unkempt condition. The RN Treatment Nurse documented that around 11:15–11:30 AM she was alerted to skin concerns and found several raised blister-like areas on the right hip and buttock, redness to the coccyx, soiled sheets, dried bowel movement on both buttocks, a shirt with a dried yellow urine smell, and a large area of dried food on the back of the shirt. CNA D and CNA E each wrote witness statements describing that when they went to get the resident up for the day, they observed dried feces on his bottom that was difficult to clean, sheets stained with feces and food, and dried food stuck to his shirt, as well as wounds that they stated were not present when he last had a shower on 12/24/2025. The DON’s witness statement also described dried bowel movement on the sheets and dried food on the resident’s clothing and bed sheets.

In interviews, CNA D and CNA E stated that their shift began at 6:00 AM, that they had looked in on the resident earlier but did not change or reposition him because he was asleep, and that the first time they attempted to change him that shift was around 11:00 AM, when the hospice aide arrived to provide a shower and the resident’s soiled condition and wounds were noted. The hospice aide reported that the resident was wearing the same shirt she had put on him at his shower two days earlier and that it was dirty with dried food, dried bowel movement, and yellow stains. The RN Treatment Nurse and DON both reported the condition and circumstances to the Administrator on 12/26/2025, and multiple witness statements were provided to him. The Administrator acknowledged receiving these statements, defined neglect as failure to provide goods or services, and stated he did not view the situation as neglect and did not conduct further investigation at that time. The incident, including the allegation of neglect involving Resident #1 and systemic skin concerns, was not reported to HHSC until 12/29/2025, beyond the 24-hour reporting requirement for allegations not involving serious bodily injury, despite the facility’s policy mirroring HHSC guidelines.