F0656

E

Inaccurate and Non–Resident-Centered Use of Confabulation in Care Plans and Documentation

Pensacola, Florida Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that resident assessments and care plans were documented accurately and in a resident-centered manner for four residents. During interviews, the MDS LPN identified the Director of Social Services (DSS) as the person responsible for entering behavior items on residents’ care plans, and the DSS stated that such directives could come from upper management, including the Administrator, Risk Manager, or DON. When surveyors questioned why a care plan entry for confabulation was added for one resident shortly after that resident made allegations of abuse, the team did not answer, and the DSS deferred responsibility to the Administrator. In a follow-up interview, the Administrator and DON stated that this resident had retracted his statement of abuse and that this was the reason confabulation was added to his care plan.

Further review showed that the term confabulation was also used in the documentation of three additional residents without clear clinical rationale provided by facility leadership. For one resident, confabulation was referenced in the summary of an investigation into a grievance in which the resident reported not being changed for 30 minutes after activating the call light, with the investigation summary stating there was “some sort of confabulation.” For another resident, confabulation was used in four nurses’ notes documenting that the resident refused care. For a fourth resident, confabulation was used in a nurse’s note stating that the resident requested to be changed after it had already been done. When asked, the Administrator and DON did not provide further explanation for the frequent use of confabulation in these residents’ charts.