Failure to Report Allegations of Neglect and Misappropriation
Penalty
Summary
The facility failed to report allegations of neglect and misappropriation of resident property for two residents, as required by federal and state law. In the first case, a resident reported that money was missing from his nightstand, and although the facility conducted an internal investigation—including reviewing security footage and interviewing staff and residents, ultimately identifying and terminating a perpetrator—the incident was not reported to the appropriate authorities. Facility policy requires that such incidents be reported, but this step was omitted. In the second case, a resident with a history of acute cholecystitis and a biliary drain reported that, during care provided by two staff members, her biliary drain was forcibly removed, resulting in a hospital transfer for replacement of the drain. The resident was cognitively intact at the time of the incident and reported the event to the social services department. Despite the seriousness of the allegation and the resulting harm, the facility did not report the incident as required. Interviews with facility leadership confirmed the failure to report both incidents.