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F0607
D

Failure to Report and Investigate Financial Abuse and Develop Protective Care Plan

Bakersfield, California Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its Abuse Prevention and Prohibition Program policy by not reporting and investigating the misappropriation of a resident's property to the California Department of Public Health and the local ombudsman. A resident, who was cognitively intact and managed his own finances, reported that his brother had made unapproved charges on his bank card after being given permission to use a limited amount. Despite multiple incidents of unapproved charges by the brother, staff did not report or investigate the situation, as the resident did not wish to press charges and was aware of his brother's actions. Interviews with staff, including the Behavioral Health Worker, Social Services Director, and Administrator, confirmed that the resident's brother had repeatedly used the resident's bank card without full approval. The Social Services Director and Administrator acknowledged the unapproved charges but did not initiate an investigation or report the incident, citing the resident's reluctance to take action against his brother. Documentation in the resident's social services notes indicated awareness of the financial abuse and discussions with the resident about the risks and benefits, but no formal reporting or investigation occurred as required by facility policy. Additionally, the facility did not develop or implement a care plan to protect the resident from further financial abuse, nor did it address the resident's refusal to be protected from his brother. The Director of Nursing confirmed that no care plans were created or updated in response to the financial abuse incidents. The facility's care planning policy requires comprehensive, person-centered care plans to address changes in a resident's condition or behavior, but this was not followed in this case.

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