F0607

J

Failure to Prevent and Investigate Misappropriation of Resident Funds

Greenville, Texas Survey Completed on 05-12-2025

Penalty

Fine: $133,425

Summary

The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically, the facility did not follow its own abuse policy for a resident with moderate cognitive impairment, who had diagnoses including dementia, anxiety, heart failure, high blood pressure, and lack of coordination. The resident was at risk for further cognitive decline and had a care plan aimed at maintaining his dignity and current level of functioning.

Staff members, including CNAs, were involved in unauthorized attempts to use the resident's debit card for ATM withdrawals. One CNA admitted to attempting a transaction after being given the card and PIN by another resident, only to discover the card belonged to the affected resident. The CNA did not report the incident immediately and later revealed knowledge of multiple occasions where the resident's funds were accessed or used by other residents, staff, and even family members of other residents. The administrator was reportedly aware of these incidents but did not take appropriate action or conduct a thorough investigation into the misappropriation of the resident's funds and unauthorized transactions.

Interviews and record reviews indicated that the resident was unaware of the extent of unauthorized use of his debit card and did not authorize others to use it beyond a single instance. Bank statements revealed multiple large withdrawals that the resident could not recall, causing him emotional distress. Despite staff and other residents being aware of the ongoing misuse of the resident's funds, the facility failed to protect the resident, did not follow its abuse policy, and did not initiate a timely or adequate investigation into the misappropriation of property.

Removal Plan

• The DON completed an assessment on Resident #9 to determine if resident was having any emotional distress related to this incident.
• The DON completed a Comprehensive Trauma screen on the resident, and resident will be referred to psychology services for further evaluation.
• The V.A. Social Worker was contacted by the facility regarding the need of the resident needing a psychology evaluation related to this incident.
• The Regional Director of Operations provided 1:1 in-service with the Regional Nurse Consultant on the facility's abuse, Neglect, and Misappropriations policy.
• The Regional Nurse Consultant provided 1:1 education to the facility DON on the Abuse, Neglect, and Misappropriations policy.
• The DON started in-service education with all staff on the facility's Abuse, Neglect, Misappropriations policy, including post-test. No staff will be allowed to work until they have completed their education.
• The Administrator was suspended by the Regional Director of Operations pending investigation.
• The resident will be taken to his bank by the Maintenance Director and Social Services to obtain a new debit card. Residents' family will be encouraged to go as well. Resident does have an active Trust fund in the facility and has access to immediate funds if he chooses.
• The Misappropriation incident was reported to HHSC by the DON.
• The Misappropriation incident was also reported to the local law enforcement agency.
• The incident was reported to HHSC by the DON regarding Resident #63 not being authorized to use Resident #9's debit card.
• Resident #63 was discharged from the facility and did not have access to resident #9's debit card.
• The facility started an investigation into the incident; the investigation was completed.
• C.N.A. E was suspended by the DON related to the incident.
• C.N.A. D was suspended and never returned to work.
• The Social Worker/designee will complete alert resident interviews 3 x week for 3 weeks, then weekly x 6 weeks to validate that all residents are allowed to make choices about aspects of his/her life in the facility, including financial choices. This will be reviewed after each interview is completed by the DON and Social Services so any issues, if applicable, can be addressed immediately.
• The Regional Nurse Consultant will oversee this process weekly x 6 weeks.
• The facility's DON notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to implement the abuse policy.
• The facility conducted an Ad Hoc QAPI meeting to discuss Misappropriation, and implementation of the abuse policy and sustaining compliance.