F0610

E

Failure to Timely Investigate and Report 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 promptly and thoroughly investigate multiple allegations of abuse and neglect, and to treat certain events as reportable alleged violations in accordance with its own abuse, neglect, and exploitation policy. The policy required immediate investigation when suspicion or reports of abuse, neglect, or exploitation occurred, including identifying responsible staff, interviewing all involved persons, and providing complete documentation. Despite this, the facility did not initiate an investigation or log an allegation related to a resident who was observed on security camera footage remaining on the smoking patio for approximately 4.5 hours without care from his assigned CNA and who was later found unresponsive at 5 p.m., after which a code blue was called. The Nursing Home Administrator (NHA), Director of Nursing (DON), and an evening supervisor each stated they did not view this sudden death as an allegation of neglect or a reportable event, and no investigation or abuse log entry was made at the time. The DON acknowledged there was no hydration cart and no supervision of the patio, and the evening supervisor confirmed there was no clear view of the resident while he was outside and that the incident was not witnessed by staff.

The deficiency also includes delayed and incomplete responses to other abuse and neglect allegations. One resident with hemiplegia and hemiparesis reported that a male staff member, identified in a psychology note as a person named by the resident, came to his room at dusk, patted his head, pinched his cheek, and asked, "how is my guy today," which the resident described as violating his space and demeaning. The NHA later described a similar allegation as involving a short-haired man who allegedly slapped the resident, but stated the resident could not provide a name and that prior similar incidents were not substantiated. The NHA acknowledged that the abuse allegation was not reported within the two-hour timeframe required by policy, instead being reported the next day to state agencies.

Another resident with hemiplegia and hemiparesis reported that during the night shift a female staff member entered her room, refused to give her the call light, stated she was not the assigned CNA and that the resident did not have a CNA, and left without providing requested incontinence care. The NHA stated that chart review showed only one documented change at 8:17 p.m. and that the assigned CNA reported being with another resident and eventually returning, but there was no exact time established. The NHA said she treated this as neglect rather than abuse because there was no physical injury, despite the facility policy defining abuse to include deprivation of goods or services. The NHA also stated she believed she had 24 hours to report if there was no injury, and confirmed that abuse allegations should actually be reported within two hours.

A further allegation involved a resident with diabetes mellitus who reported being abused by staff because a nurse would not leave medications at the bedside and the resident refused care from her CNA that night. The NHA stated she did not consider this to be abuse, even though the resident alleged abuse, and that she found it odd but did not question the CNA further after the CNA reported that nothing had happened on her shift. The resident later accepted care and medication from another nurse, and the NHA reported the matter as neglect, not abuse. The NHA also stated that the resident refused to be interviewed by her on two occasions and that she did not know what the resident meant by being abused and never found out. Across these incidents, the Regional Director of Clinical Services confirmed that no reports were filed or investigated for the resident who died after being on the patio, and that the NHA failed to file required reports within policy timeframes, despite the job description requiring the NHA to operate the facility in accordance with federal, state, and local regulations and to review resident complaints and grievances with appropriate written follow-up.