Failure to Conduct Thorough Investigation of Alleged Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation involving a resident's missing wallet and identification cards. The resident, who had a history of Alzheimer's disease, unspecified psychosis, and hallucinations, was reported by a responsible party to be missing a wallet containing a state identification card and social security card. The resident's cognitive status was moderately impaired, as indicated by a BIMS score of 12. The responsible party notified the Social Services Director (SSD) via email, and a formal grievance was filed, with the facility offering to assist in replacing the missing items. Despite the facility's policy requiring timely and thorough investigations of all reports and allegations of abuse or misappropriation, the investigation did not include interviews or statements from staff who cared for the resident. The investigation consisted of interviewing the resident, searching for the wallet, and interviewing other residents, but omitted staff interviews. Multiple staff members, including LPNs, CNAs, and a Trained Medication Aide, confirmed during subsequent interviews that they had not been asked about the missing wallet and were unaware of the incident. Facility documentation, including the Monthly Grievance Log, Complaint/Grievance Report, and state agency reports, confirmed that the investigation was incomplete. The SSD and Administrator both acknowledged that investigating such allegations was a group effort, but the Administrator stated that she expected the investigation to include staff interviews, which did not occur. This failure to follow investigative protocols resulted in an incomplete investigation of the alleged misappropriation.