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F0610
D

Failure to Investigate and Safeguard Resident's Missing Cash

San Francisco, California Survey Completed on 12-04-2025

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

The facility failed to thoroughly investigate a resident's report of missing personal property, specifically a black pouch containing cash. The resident, who had diagnoses including acute respiratory failure, recurrent major depressive disorder, generalized anxiety disorder, and hoarding disorder, reported that the pouch with approximately $2,000 was missing following a transfer to the hospital. The resident had previously shown a Certified Nursing Assistant (CNA) $1,000 in the pouch, and the CNA confirmed seeing and returning the pouch to the resident in the weeks prior to its disappearance. However, the pouch and cash were not documented in the resident's inventory, and the facility did not take further action after the CNA verified the presence of the cash. The investigation conducted by the facility included interviews with staff and review of documentation, but no evidence or report of wrongdoing by staff, residents, or visitors was found. The interdisciplinary team determined that the allegation was unverified, and the missing items were not recovered. The CNA involved received training on the proper process for documenting resident property and the facility's policy for safeguarding valuables, but this was after the incident had occurred. Throughout the process, the resident experienced significant emotional distress, including tearfulness, sadness, and feelings of distrust toward staff. The resident continued to express sadness and depression related to the loss of the cash, and social services provided ongoing support and referred the resident to a psychologist. The facility's policies required inventorying resident belongings and safeguarding valuables, but these procedures were not followed in this case, contributing to the loss and the resident's emotional response.

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