Failure to Investigate and Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or mistreatment were thoroughly investigated for one resident who was deaf, non-speaking, and cognitively intact. The resident, who communicated primarily through American Sign Language, gave a staff member a significant sum of money to hold. When the resident later requested the money back, only a portion was returned, and the staff member could not account for the full amount. The incident was brought to the attention of facility administration by the Ombudsman, but there was no timely or documented investigation initiated, and the event was not reported to the appropriate state authorities as required by facility policy and regulation. Multiple interviews revealed that the facility's response was delayed and incomplete. The initial notification of the incident occurred weeks before any formal investigation was started, and the resident's communication needs were not adequately accommodated during the inquiry. Instead of using a certified interpreter, staff attempted to communicate with the resident using a whiteboard, which may not have allowed for a full understanding of the resident's perspective or consent. Key staff members, including social workers and nursing management, were either unaware of the incident or did not follow through with required reporting and documentation procedures. Facility records, including the grievance log and accident/incident reports, did not reflect the incident involving the resident's money. The administrator and other staff provided inconsistent accounts of when they became aware of the situation and what actions were taken. The staff member involved eventually returned some of the money, but receipts for the missing amount were not provided, and the administrator did not consider the unaccounted funds as misappropriated. The lack of timely investigation, failure to use appropriate communication methods, and absence of required reporting constituted a deficiency in responding to alleged violations involving resident property.