F0842

E

Failure to Document Abuse and Resident-to-Resident Incidents in Medical Records

Tampa, Florida Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records related to alleged abuse and neglect incidents for three residents. For one resident with osteomyelitis, diabetes, mood disorder, history of falls, hypertension, lymphedema, and a left below-knee amputation, the resident reported a verbal altercation with a night RN during medication administration involving fast-acting insulin. The resident, who was cognitively intact per a BIMS score of 15, stated the nurse told him not to tell him how to do his job, made an explicit comment, and repeatedly returned and harassed him. The Nursing Home Administrator (NHA) later confirmed through interview with the nurse that the nurse admitted to disrespectful verbal exchanges and name-calling. Despite this, there was no documentation in the resident’s medical record—no progress note or SBAR entry—describing the incident, the nursing assessment, or notifications, even though the facility’s own leadership stated such documentation was expected.

For a second cognitively intact resident with multiple diagnoses including interstitial pulmonary disease, COPD, diabetes, asthma, cognitive communication deficit, depression, dialysis, CHF, and hypertension, staff requested a psychiatric evaluation following an episode of agitation in which the resident reportedly pushed another resident’s walker. The psychiatric note documented the episode and the resident’s response during the evaluation, including that he was newly admitted for rehabilitation, had a hard year, became paranoid during the interview, and declined psychiatric medications. However, the resident’s medical record contained no nursing progress notes or SBAR assessment related to this resident-to-resident incident. Additionally, there were no care plan updates to address the behaviors or the incident, despite the occurrence of an altercation between residents.

For a third resident with schizoaffective disorder, bipolar type, COPD, seizures, chronic pain, anxiety, depression, and hypertension, a psychiatric progress note documented that the resident was seen following a resident-to-resident incident in which she was bumped in her wheelchair by another resident. The note stated the resident was calm, cooperative, had no adverse effects, denied abuse or neglect, and had no psychosocial distress or injuries. Interviews with the NHA and Nurse Consultant clarified that the incident involved one resident bumping another’s wheelchair on the smoking patio and making a threatening statement, after which the residents were separated and monitored. Despite this, the medical record for the resident who was bumped contained no nursing progress notes, SBAR, or assessment documenting the incident. The record for the resident who did the bumping also lacked any documentation of the incident, including progress notes, SBAR, assessment, or care plan updates, even though facility leadership stated they expected such documentation and care plan revisions after incidents.

The facility’s own policies on abuse, neglect, exploitation, and plans of care require thorough nursing evaluation, documentation of incidents, and care plan review and revision in response to changes in resident needs or incidents. The NHA and Nurse Consultant acknowledged that there was no documentation in the medical records for these incidents and that nursing staff had not been educated on documentation requirements post-incident, including progress notes, SBAR, assessments, and care plan updates. The NHA also acknowledged that although the reportable investigation form indicated that progress notes had been reviewed, the progress notes related to the incidents were not actually present in the records. This lack of required documentation for alleged abuse and resident-to-resident incidents constitutes the cited deficiency in maintaining complete and accurate medical records in accordance with accepted professional standards.