F0835

F

Failure to Investigate and Report Alleged Neglect of Resident Left Unattended on Smoking Patio

Tampa, Florida Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

Facility administration failed to utilize resources effectively to ensure allegations of abuse and neglect were thoroughly investigated and reported in a timely manner for multiple residents. The Nursing Home Administrator’s job description required directing day-to-day functions in accordance with federal, state, and local regulations to assure quality care, including reviewing resident complaints and grievances, maintaining written records of complaints, and reporting all allegations of resident abuse and misappropriation of property. The DON’s job description outlined responsibilities for ensuring quality and safe delivery of nursing services, accurate and timely documentation, continuous observation and monitoring of seriously ill residents, and acting as a patient advocate. Despite these defined roles and responsibilities, the facility did not ensure that an allegation of neglect involving a resident on the smoking patio was properly investigated, documented, or reported.

Resident #3 was admitted with serious medical conditions including metabolic encephalopathy, major depressive disorder, antineoplastic chemotherapy, secondary malignant neoplasm of the lung, malignant neoplasm of the brain, severe calorie malnutrition, cachexia, COPD, personal history of pneumonia, and acute respiratory failure with hypoxia. A witness statement dated on a specified date described security camera footage from the smoking patio showing this resident, who was assigned to a specific CNA for care, entering the smoking patio in the afternoon and remaining there without any visits or care from the assigned CNA. The statement indicated that at 5 p.m. the resident was found unresponsive by other staff, assisted indoors, and a code blue was called, with the video showing that the resident received no care of any kind from the assigned CNA for over 4.5 hours. Review of the facility’s abuse log for the relevant period showed that this incident was not listed, indicating it was not entered into the abuse/neglect tracking system.

During a complaint survey, interviews with key personnel who were employed at the time of the incident revealed they were not willing or able to participate meaningfully in the survey process regarding the investigation of abuse and neglect. The RN Unit Manager, Director of Rehabilitation, Housekeeping Manager, Assistant DON, two Social Services Directors, and therapy staff denied knowledge of the resident having been left unattended for 4.5 hours, or that the resident coded, required CPR for more than 10 minutes, and subsequently expired. Their responses included statements such as not remembering the incident, not being told anything by administration, not knowing, not feeling comfortable answering, or lacking specifics. At the time of the investigation, it was unclear whether these key staff had not participated in any investigation of this traumatic event or were not forthcoming, which impacted the survey process. Review of the facility’s Compliance and Ethics Reporting policy showed that employees were required to report suspected violations immediately and that all reports were to be investigated and tracked for QAPI, but the handling of this incident and the absence of the event from the abuse log demonstrated that these reporting and investigation processes were not effectively implemented by facility administration.

Further, interviews with the RDCS and the facility’s CNO revealed that they only became aware of the witness statement about the resident being left outside for 4.5 hours shortly before the survey interview and that the allegation of neglect had only then been reported. They stated that the LPN who wrote the witness statement had focused on the caregiver rather than the resident and that the LPN had not reviewed the full 4.5 hours of video. The RDCS stated that administration was not forthcoming and that there had been an unsupervised smoking patio at the time of the incident. The CNO reported discovering that the NHA had a culture of hiding information and that the NHA had concealed matters from them. These statements, combined with the lack of timely reporting, incomplete or absent investigation, and failure to document the incident in the abuse log, demonstrate that facility administration did not administer the facility in a manner that ensured effective use of resources to investigate and report allegations of abuse and neglect as required by policy and job responsibilities.