F0610

D

Failure to Thoroughly Investigate Resident Allegation and Unexplained Bruising

Pinellas Park, Florida Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of mistreatment and unexplained bruising for one resident. The resident, who had intact cognition per a recent BIMS score of 14 and diagnoses including traumatic subarachnoid hemorrhage, hemiplegia/hemiparesis, epilepsy, aphasia, major depressive disorder, and need for assistance with personal care, reported that an incident occurred while being changed by a CNA. She described being on the right side of her bed with her wheelchair facing the nightstand, and stated that her right and left forearms were crossed with palms down and pressed against the bed and wheelchair surface by an aide, causing pain to her wrists and bruising on her forearms. On observation, she had two penny-sized dark pink spots on the inside of both forearms near the wrists.

Prior to the survey interview, therapy and clinical staff had already noted bruising and an allegation related to care. A COTA reported that during a therapy session later identified as occurring on 12/22/2025, she observed dark purple, fresh-appearing bruises on the resident’s inner forearms when asking her to show her arms for an exercise. When questioned, the resident requested to speak with the person in charge and indicated the bruising was related to two aides she was upset with. A Nurse Practitioner skin and wound assessment on the same date documented scattered bruises to the upper extremities and assessed a contusion of an unspecified upper arm. A psychiatry note dated 12/24/2025 documented that the resident alleged a CNA had grabbed her in a manner she found uncomfortable during assessment, but she was unable to describe the CNA or provide specific details; the psychiatrist noted no injuries or signs of distress at that time. A social services note on 12/23/2025 indicated that, due to an injury of unknown origin, a BIMS interview was attempted, but the resident declined to answer questions and refused to participate.

The facility’s own skin and wound policy required CNAs to report skin changes to licensed nurses, licensed nurses to document new skin impairments and report changes in skin integrity to the practitioner and responsible party, and to develop individualized goals and interventions on the care plan, with weekly documentation until resolution. The resident’s care plan already identified potential/actual skin integrity impairment related to decreased cognition, decreased mobility, fragile skin, and incontinence, with interventions including monitoring and documenting skin injuries, reporting abnormalities to the physician, and using caution during transfers and bed mobility to prevent striking extremities against hard surfaces. During interview, the NHA and DON acknowledged that therapy staff had noticed bruising and that the resident alleged the bruising occurred during care, but the DON stated she was unaware of the bruising prior to the incident despite the resident being on an anticoagulant, and the NHA stated they interviewed everyone on shift but could not identify the CNA involved. The NHA also stated they had not spoken to the Nurse Practitioner who documented the bruising. The facility was unable to determine how the resident acquired the bruising or identify a perpetrator, demonstrating that a thorough investigation of the allegation and injury of unknown origin was not completed.