Failure to Report and Investigate Suspected Misappropriation and Exploitation
Penalty
Summary
The facility failed to timely report and investigate potential misappropriation and exploitation involving a resident with multiple sclerosis, neurogenic bladder, anxiety, and depression, who was cognitively intact. Pharmacy records showed that between 21 and 33 tablets of Sildenafil Citrate prescribed to the resident were unaccounted for, and the facility could not provide documentation regarding the missing medication or any audits of medication storage. Only one RN administered the medication, and there was no documentation of whether one or two tablets were given at each administration. Multiple staff members reported knowledge of an inappropriate relationship between the resident and the RN, including physical contact, exchange of money, and rumors of the RN taking resident medications for personal use. Staff interviews indicated that these concerns were reported to facility leadership, but the facility did not confirm the incidents or report them to authorities, citing the resident's denial and intact cognition as reasons for not proceeding with a report. The facility's own policy required immediate investigation and thorough documentation of any suspected abuse, neglect, or exploitation, including interviewing all involved parties and preserving evidence. Despite this, the facility did not follow its procedures, as there was no evidence of a comprehensive investigation or timely reporting to the appropriate authorities regarding the suspected misappropriation and exploitation.