F0842

E

Incomplete Admission Assessment and Lack of Daily Skilled Documentation

Tampa, Florida Survey Completed on 02-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurately documented medical records for a resident admitted with multiple complex medical conditions, including other artificial openings of urinary tract status, retroperitoneal fibrosis, stage 4 chronic kidney disease, unsteadiness on feet, generalized muscle weakness, need for assistance with personal care, and oropharyngeal dysphagia. The Admission/readmission Nursing Evaluation dated 1/30/26 at 5:41 p.m. was not completed and locked, with sections a, l, and n left unsigned. Section a lacked documentation of how the resident was transferred to the facility, whether there were weight-bearing restrictions, and did not document the presence of a nephrostomy tube. Section l did not include an evaluation for mechanical lift use or the resident’s ability to stand, pivot, or transfer with assistance, and section n did not show that medications were reviewed and verified.

Record review showed that the Daily Skilled Note assessment had not been accessed or completed for this resident, despite the resident being on a skilled level of care and receiving specialized services and skilled nursing. The progress notes did not contain an admission note. Nursing documentation consisted primarily of eMAR entries related to administration of oral and topical pain medications and associated effectiveness checks, along with a single general note on 1/30/26 indicating a skin concern on the coccyx and notification of the emergency contact, and a skin/wound note on 2/2/26 documenting scar tissue to the sacrum, a surgical site to the right flank with minimal serous drainage and treatment in place, and scar tissue to the abdomen. There were no nursing eMAR or progress notes documenting the resident’s overall wellbeing on 2/4/26.

A late entry note dated 2/7/26 for 2/6/26 at 9:30 a.m. documented that nursing was called to the resident’s room by administrative staff, that the resident did not appear to be in respiratory distress, and that a family friend and family member expressed concern and requested transfer to the hospital; EMS arrived before staff could obtain vital signs. Interviews with the Director of Rehab indicated the resident was receiving physical and occupational therapy in the room, had refused to go to the gym, and was status post nephrostomy placement. The ADON and Interim DON stated that, as a skilled resident, there should have been daily skilled charting notes, but these were not present. The NHA confirmed the Admission/readmission Evaluation was not completed and that there were no daily skilled notes other than a late entry for the resident’s departure. Staff C, an LPN, could not recall specific information about the resident from the chart. The facility’s documentation policy required objective, complete, and accurate documentation of services, assessments, treatments, and changes in condition, but there was no policy provided specific to completing an admission assessment or daily skilled notes.