Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to conduct a thorough investigation into two allegations of misappropriation of resident funds involving two residents with severe cognitive impairment. Both residents had significant medical and cognitive conditions, including dementia, schizophrenia, and hemiplegia, which limited their ability to express their needs or preferences. The allegations centered on purchases made from the residents' trust accounts by a former Assistant Administrator, with concerns raised by staff that items purchased may not have been delivered to the intended residents and that receipts were not properly managed or verified. The facility's internal investigation primarily involved the Administrator independently reviewing receipts and comparing them to items found in the residents' rooms, without interviewing relevant staff or obtaining written witness statements. Staff interviews revealed that purchased items remained in bags at the nurse's station for weeks, and staff repeatedly requested receipts to verify and distribute the items, but these were not provided in a timely manner. There were also discrepancies in the sizes and types of items purchased compared to the residents' known needs, as reported by multiple CNAs familiar with the residents' care routines. Documentation provided by the facility included partial and reprinted receipts, which lacked clear identification of the place of purchase and did not include signatures from the purchaser, residents, or staff to confirm receipt and delivery of items. The facility Administrator did not report the allegations to the state regulatory agency as required by policy, and did not interview staff or preserve physical evidence as outlined in the facility's abuse investigation protocols. The investigation was completed without comprehensive documentation or staff involvement, and the facility failed to follow its own policies for reporting and investigating allegations of abuse or misappropriation.