Failure to Document Thorough Investigations of Alleged Neglect and Misappropriation
Penalty
Summary
The facility failed to provide evidence that allegations of neglect and misappropriation of property were thoroughly investigated for two residents. In the first case, a resident with severe cognitive impairment (BIMS score of 0) was reported to have fallen out of bed and remained on the floor for approximately three hours without staff rounding. The facility's incident report did not include documentation of interviews with all staff present during the incident, communication with the resident's family, or findings from a review of facility video footage. The Administrator confirmed that there was no documentation of these investigative steps, despite having viewed the video. In the second case, a resident with intact cognitive function (BIMS score of 15) reported unauthorized transactions on his bank statement and missing cash from his wallet. The grievance report was incomplete, lacking follow-up documentation. The Administrator stated that an investigation was conducted but could not provide evidence that the allegation of misappropriation of property was thoroughly investigated. The corporate nurse confirmed that administrators are expected to document all interviews and retain all investigation-related documents, which was not done in these cases.