Failure to Implement Abuse and Misappropriation Reporting and Investigation Procedures
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation policy and procedure by not maintaining complete evidence of investigations into misappropriation of property and not immediately reporting allegations of abuse to the Administrator or designee, as well as not notifying local law enforcement or Adult Protective Services (APS) for several abuse or misappropriation allegations. In one instance, medications belonging to multiple residents were found in a nurse's personal bag at the nurse's station. The facility's investigation included a statement from the nurse and interviews with alert and oriented residents, but lacked documentation such as the names and amounts of medications found. Attempts to interview the nurse were unsuccessful, and the former DON reported that documentation of her investigative actions was missing. The Administrator and Corporate Nurse were unable to account for the missing documentation or recall all investigative steps taken. In another case, an allegation of possible diversion of a resident's liquid Morphine was reported after the medication was found to be an abnormal color. The allegation was not reported to law enforcement or APS, and the Social Worker stated she did not notify these agencies because she was not instructed to do so by the Administrator. The investigation included interviews with nurses and returning the medication to the pharmacy, but the reporting requirements to external agencies were not met. The Administrator confirmed that the Compliance Officer did not instruct him to notify law enforcement or APS. A further incident involved an allegation of resident abuse related to a nurse's conduct and medication administration. The allegation was not reported to law enforcement or APS, and the initial report was not submitted within the required two-hour timeframe. The Social Worker and Administrator both indicated that reporting to external agencies was not completed because they were not instructed to do so. The investigation documentation was incomplete, and key staff involved were unavailable for interview. These failures demonstrate lapses in following the facility's own policies and regulatory requirements for reporting and investigating abuse, neglect, and misappropriation allegations.