Failure to Investigate Allegations of Misappropriation and Neglect
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of funds for a resident with a history of depression, stroke, and spinal cord dysfunction. The resident, who was cognitively intact and required assistance with activities of daily living, reported $40 missing from a bedside table, which was intended for a hairdresser appointment. The resident stated the missing money was reported to a nurse aide approximately six months prior, but no action was taken by the facility. The nurse aide recalled searching for the money and reporting the incident to a supervisor, including submitting a written statement, but there was no documentation or evidence that the incident was investigated or reported by facility management. The administrator and director of nursing were unaware of the allegation and could not explain why the policy was not followed or why the incident was not investigated at the time it was reported. For another resident with severe cognitive impairment, dementia, and incontinence, the facility failed to thoroughly and promptly investigate an allegation of neglect. The resident's family reported that the resident had not received incontinence care, position changes, or hygiene for many hours, resulting in a saturated brief, foul odor, and new skin irritation and open areas. The incident was reported to staff on the day it occurred, but the investigation was not initiated until eight days later, and the state agency was not notified until ten days after the initial allegation. Written statements from staff were collected days after the event, and the investigation lacked key components, such as summaries of interviews and a conclusion regarding the substantiation of neglect. Additionally, the staff member accused of neglect was not immediately suspended as required by facility policy and continued to have access to the resident for several days following the allegation. The director of nursing indicated that the investigation was incomplete and lacked a summary, root cause, and corrective actions. The decision not to substantiate neglect was based on the family member later expressing comfort with the staff member, rather than on a thorough investigation of the care provided.