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F0600
D

Resident's Rights Violated During Medication Administration

Tampa, Florida Survey Completed on 06-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with severe cognitive impairment, vascular dementia, psychosis, and major depressive disorder was observed to have her rights violated when a nurse used physical force to administer medication. The resident, who had a history of being resistive to care and difficulty communicating due to expressive aphasia, repeatedly refused her medication by spitting it out. Despite this, the nurse attempted to administer the medication multiple times, ultimately resorting to holding the resident's nose and mouth closed while using a syringe to force the medication into her mouth. Multiple staff members witnessed the incident and reported that the resident verbally expressed her refusal by saying, "I don't want it, I don't want it." The nurse admitted to the action, stating that she did not act maliciously and referenced using a similar method with her own children. The incident was documented in a psychiatric note, which confirmed the nurse's admission and the resident's ongoing difficulty with communication and resistance to care. The facility's policy prohibits all forms of abuse, including physical abuse, and requires immediate reporting of any alleged violations. The actions taken by the nurse were inconsistent with the resident's care plan, which emphasized respecting refusals, using redirection, and allowing time for the resident to adjust. The incident was not immediately reported by the witnessing CNAs, but was later brought to the attention of the Director of Nursing, who confirmed that the resident's right to refuse medication should have been honored.

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