DFW Nursing & Rehab couldn't locate the Patient Incident Report for a November complaint involving Resident #4, who had been hospitalized by the time inspectors arrived on November 20. The facility's current administrator blamed his predecessor, telling inspectors the former administrator "was disgruntled when he was fired" and promised to leave all paperwork but "didn't leave any paperwork at all."
The missing documentation violated federal requirements that nursing homes maintain thorough investigation records for regulatory review.
Resident #4's incident began after a shower when she became agitated and refused to get dressed. Med Tech F told inspectors the resident "willingly got on the floor" in her room while naked and repeatedly said she wanted to go to Hospital Name 2, which Med Tech F described as "Resident #4's hospital of choice whenever she wants to be sent out to the hospital."
The medication technician said Resident #4 "always gets on the floor when she doesn't get her way" and wasn't injured during the incident. Staff couldn't lift the resident from the floor and she wouldn't get up herself, so they called 911 for assistance.
But when inspectors requested the Patient Incident Report documenting the investigation, the facility couldn't produce it.
The Director of Nursing told inspectors she "could not find the PIR for intake 1034343." She explained that the previous administrator would have maintained the missing report since the incident occurred during his tenure, but "they couldn't find any information the old administrator had."
Despite the missing documentation, the nursing director recalled details of the incident. She confirmed that Resident #4 "got on the floor while she was naked and kept saying she wanted to go to the hospital" and that staff called emergency services because "they couldn't pick the resident up off the floor and the resident wouldn't get up by herself, and they couldn't drag her."
The nursing director emphasized that Resident #4 "was not hit by any of the staff" during the incident.
When pressed about the missing records, the nursing director acknowledged the facility "are expected to keep all PIR's to have them for future references." She warned that without proper documentation, facilities risk "investigations to not be thoroughly done, poor patient care, and fines."
The current administrator, who wasn't in position during the incident, told inspectors he couldn't discuss what happened because he had "no PIR to reference." He confirmed that maintaining Patient Incident Reports "typically it's the administrator's job."
He described the fired administrator as uncooperative during the transition. The former administrator "told him that he was going to make sure he gave him all the paperwork from the previous incidents, but he didn't leave any paperwork at all."
The administrator acknowledged that missing investigation records create regulatory risks. "The facility can be fined for not having that information for surveyors to reference," he told inspectors.
The facility's abuse policy requires comprehensive documentation of all incidents. According to policy documents reviewed by inspectors, "All reports of resident abuse (including injuries of unknown origin) are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management."
The policy mandates that administrators "immediately report his or her suspicion" to state licensing agencies and "initiate investigations" of all allegations. Within five business days, administrators must "provide a follow-up investigation report" with "sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified."
The policy emphasizes that follow-up reports should "provide as much information as possible at the time of submission."
But none of this documentation existed for Resident #4's incident when inspectors arrived.
The missing records left inspectors unable to verify whether the facility properly investigated the incident, reported it to appropriate agencies, or implemented corrective measures. They couldn't determine if staff followed proper protocols when responding to a naked resident on the floor or confirm the timeline of events leading to the 911 call.
The documentation gap also prevented inspectors from reviewing whether the facility identified any systemic issues that might prevent similar incidents. Without the investigation report, they couldn't assess if staff received additional training or if policies were modified based on the incident's findings.
Med Tech F's account suggested Resident #4 had a pattern of getting on the floor "when she doesn't get her way," but inspectors couldn't review whether previous incidents were properly documented or if the facility developed specific care plans to address this behavior.
The facility's current leadership expressed frustration with the situation but accepted responsibility for the missing records. The administrator acknowledged that regardless of the circumstances surrounding his predecessor's departure, the facility remained accountable for maintaining required documentation.
The nursing director's ability to recall incident details demonstrated that staff retained institutional knowledge about what occurred, but federal regulations require written documentation that can be reviewed and verified by inspectors.
The violation highlighted broader risks associated with administrative transitions in nursing homes. When leadership changes occur, facilities must ensure continuity of record-keeping and regulatory compliance, particularly for sensitive matters involving resident safety and potential abuse allegations.
Federal inspectors classified the violation as causing minimal harm with potential for actual harm, affecting few residents. However, the missing documentation created ongoing compliance risks and prevented thorough regulatory oversight of resident protection protocols.
The incident occurred at a time when Resident #4 was already hospitalized, leaving inspectors unable to interview her about her experience or verify staff accounts of what transpired in her room that day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dfw Nursing & Rehab from 2025-11-20 including all violations, facility responses, and corrective action plans.