F0609

E

Failure to Timely Report and Investigate Multiple Abuse and Neglect Allegations

Tampa, Florida Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report and investigate multiple allegations and indications of abuse and neglect in accordance with its own Abuse, Neglect and Exploitation policy and federal reporting timeframes. The policy required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but not later than 2 hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. The policy also defined an "alleged violation" as any situation or occurrence observed or reported that, if verified, could indicate noncompliance with federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. Despite this, the facility did not treat several events as reportable allegations and did not report them within the required timeframes.

For one resident with multiple serious diagnoses including metabolic encephalopathy, major depressive disorder, metastatic cancer to the lung and brain, severe calorie malnutrition, cachexia, COPD, history of pneumonia, and acute respiratory failure with hypoxia, a written witness statement described security camera footage showing the resident entering the smoking patio in the afternoon and remaining there for the entire afternoon without any visits or care from staff or the assigned CNA. The statement indicated that at 5 p.m. the resident was found unresponsive by another staff member, brought indoors, and a code blue was called, and that the resident did not receive care from the assigned CNA for over 4.5 hours. This statement was signed and dated by an LPN. The incident did not appear on the facility’s abuse logs, and the NHA, DON, and an LPN supervisor each stated they did not investigate or report the event as an allegation of neglect or a reportable event, citing reasons such as viewing it as a "regular code," believing the resident’s terminal diagnoses and poor prognosis made the death unsurprising, and stating there was no supervision of the patio at that time. The LPN who wrote the statement later said the statement about the resident remaining unattended for 4.5 hours was false and that her focus was on the CNA’s performance, but also stated that administration was aware of the statement and did not report or investigate it.

For another resident with hemiplegia and hemiparesis, a psychology progress note documented that the resident, who was alert and oriented, reported that a person identified by name came to his room at dusk, patted him on the head, pinched his cheek, and made a familiarizing comment, which the resident described as violating his space and demeaning. The NHA stated that the resident had alleged that a short-haired man slapped him and that he reported this to a nurse two days prior, and that the resident had a similar prior allegation. The NHA reported that the incident was assessed with no injuries and that she did not have a name to go by, and she did not identify the named individual from the psychology note as part of the investigation. She acknowledged that she reported the incident to DCF and AHCA the day after the event and that this did not meet the facility’s policy requirement to report within two hours.

For a third resident with hemiplegia and hemiparesis, the abuse log showed an incident in which the resident reported that a female staff member entered her room during the night shift, refused to give her the call light, stated she was not the resident’s assigned CNA and that the resident did not have a CNA, and then left without changing the resident despite the resident’s stated need. The NHA stated that when she reviewed the chart, she saw documentation of the resident being changed only once at 8:17 p.m. and that the assigned CNA reported being with another resident and eventually returning, but there was no exact time. The NHA said the resident had glaucoma and could not clearly identify the staff member, and that the resident later told psych it was probably a misunderstanding and denied being abused. The NHA stated she treated this as a neglect incident, not abuse, because there was no physical injury, and reported the incident to AHCA more than 24 hours after she was notified, despite acknowledging that abuse allegations should be reported within two hours and that the policy defined abuse to include deprivation of goods or services.

For a fourth resident with muscle wasting and atrophy, cognitive communication deficit, and unspecified dementia, the abuse log and psychology note documented that the resident reported three people (one male and two females) in her room, with the male asleep in her bed and one female hitting her, then feeding others before all left. The NHA stated that a family member alleged the resident was beaten up by staff and that she was notified when the incident happened. She reported that she notified DCF and AHCA more than two hours after the allegation, explaining that she was with the police and unable to report sooner. The NHA acknowledged that reporting of abuse incidents should occur within two hours. The Regional Director of Clinical Services confirmed that there were no reports filed or investigations conducted for the resident who died on the patio and stated that the NHA should have filed reports within the required timeframes and that another staff member could have submitted reports if the NHA was unavailable.