F0609

G

Failure to Timely Report Alleged Neglect Involving Dummy Call Lights

Athens, Texas Survey Completed on 02-13-2026

Penalty

Fine: $138,600

Summary

The deficiency involves the facility’s failure to recognize and report allegations of neglect related to the use of non-functioning or inaccessible call lights, and to report these allegations to the state agency within required timeframes. On 02/02/26, the Social Worker received grievances from a CNA alleging that another CNA had been switching out working call light cords/buttons with dummy ones that did not work for three residents. These grievances identified that the alleged conduct occurred on evening/weekend shifts and involved residents who were care planned to have call lights within reach and to use them to request assistance. The Administrator acknowledged receiving grievances about fake call lights on 02/02/26 and understood that residents were being given call lights that did not function or were pulled from the wall.

Resident #1 was an older male with cervical disc disorder with myelopathy, Parkinson’s disease, dementia, cervical spinal cord injury, neurogenic bowel, and neuromuscular bladder dysfunction. He had severe cognitive impairment, significant functional limitations in all extremities, was dependent or required substantial assistance for most ADLs, and was always incontinent of bowel and bladder. His care plan for falls required that his call light be placed within reach and that he be encouraged to use it for assistance. Multiple staff and a family member reported or described situations in which his call light was out of reach, unplugged, or replaced with an extra call light. The HR Director and a CNA each described finding two call lights on his side of the room, with one plugged in and draped over furniture and another coiled on the floor or in his hand and not plugged in. His roommate reported that a CNA moved his call light out of reach and that he had to return it to him, and that this had been ongoing for at least a month.

Resident #3, an older female with type 2 diabetes, dementia, a thoracic vertebral compression fracture, and dysphagia, had intact cognition and required supervision or assistance with transfers, toileting, and bathing. Her falls care plan included education on use of the call light and placement of the call light within reach. A grievance documented that a CNA reported Resident #3 stated that a night aide had put her call light out of reach and placed another light in her room that was not plugged in as a dummy light. Resident #4, an older female with a displaced right femur fracture, major depressive disorder, dementia, and repeated falls, had moderate cognitive impairment and required substantial assistance with transfers and ADLs. Her care plan noted that she would call out loudly instead of using the call light and directed staff to redirect her to use the call light, with interventions to keep the call light within reach. A grievance documented that a CNA reported concerns that another CNA had possibly been switching out Resident #4’s call light with a dummy one that did not work.

Despite these allegations, the facility did not treat them as reportable abuse/neglect events and did not report them to the state agency within the required 24-hour timeframe. The Social Worker stated she informed the Administrator on 02/02/26 of allegations that an aide was moving working call lights out of reach and using extra dummy call lights for three identified residents. The DON stated she became aware of someone doing this with call lights during a clinical meeting on 02/03/26 and that she informed the Administrator that day, and she acknowledged that this could be considered neglect or seclusion and should have been reported to the state. The Administrator confirmed she received a grievance about fake call lights on 02/02/26, learned the names of the two potentially involved CNAs by 02/03/26, and acknowledged that the situation could be considered neglect or seclusion and should have been reported to the state, but it was not. The facility’s handling of the grievances as internal complaints without timely reporting to HHSC constituted the failure to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, or within 24 hours when not involving abuse or serious bodily injury, to the administrator and appropriate state officials.

Additional interviews and observations further supported that the facility had information suggesting possible misuse of call lights but did not initiate required external reporting. The HR Director described finding two call lights on Resident #1’s side of the room in late December, with one unplugged on the floor, and she took the unplugged light to the ADON but did not notify the Administrator. Another CNA reported finding an extra call light in Resident #1’s hand that was not plugged in while his regular call light was plugged into the wall and draped over his bedside drawers, and she reported this to the DON and gave the extra light to the HR Director. A family member of Resident #1 reported to the DON and Administrator that she had been told by several people that two CNAs were unplugging his call light and giving him a fake one, and she provided recordings showing that the DON and Administrator were aware of these allegations. The Administrator later acknowledged that the two identified aides should have been suspended immediately and that the failure to do so and the failure to report the allegations to HHSC put residents at risk for further neglect, seclusion, and mistreatment.