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F0602
D

Failure to Protect Resident from Exploitation by Staff

Lexington, North Carolina Survey Completed on 09-02-2025

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

A nurse aide (NA) at the facility engaged in conduct that failed to protect a resident's right to be free from exploitation. The NA discussed her personal housing difficulties with a resident who was moderately cognitively impaired, suffering from depression, anxiety, and a cognitive communication disorder. The NA asked the resident if she could live in his personal home while he was at the facility, and the resident, described as goodhearted and trusting, considered allowing the NA and her friend to house-sit. The resident provided information about where the house key was located, and the NA attempted to access the home by searching for the key and then requesting it from the resident's neighbor. The neighbor refused to provide the key and notified the resident's family member, who was the financial proxy and health power of attorney. The family member and neighbor reported the incident to facility administration. Interviews with the resident, the NA, the neighbor, and the family member revealed that the resident initially agreed to allow the NA to stay at his home but changed his mind after learning more about the NA's personal situation. The NA claimed her intent was to assess the home for providing private care after the resident's discharge, but she admitted to going to the house and seeking the key from the neighbor. The neighbor and family member both stated that the NA expressed a desire to stay in the resident's home, and the family member emphasized the resident's vulnerability due to his cognitive and emotional state, as well as his use of pain medications. The NA was suspended and subsequently terminated for attendance issues, but the facility's initial investigation did not substantiate the allegation of exploitation, focusing instead on the lack of harm and the fact that the NA did not gain access to the home or property. Despite the lack of physical harm or property loss, the facility failed to recognize and substantiate the exploitation that occurred when the NA attempted to benefit from her relationship with a vulnerable resident by seeking access to his personal home. The former administrator later acknowledged that the situation should have been substantiated as exploitation, given the NA's actions and the resident's inability to fully understand the ramifications. The facility did not complete a plan of correction for misappropriation of property or exploitation related to this incident.

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