Failure to Timely Report and Investigate Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to report the suspected misappropriation of a resident's amethyst stone ring to the Illinois Department of Public Health (IDPH) in a timely manner. The incident involved a resident with severe cognitive impairment, whose family had gifted her the ring for her birthday. The ring was last seen before Thanksgiving, and its disappearance was reported by the resident's family member to staff. Multiple staff members, including CNAs and the Social Service Director, were made aware of the missing ring, and some staff conducted a search of the resident's room. However, there was no documentation of an investigation or timely reporting to IDPH at the time the ring was discovered missing. Interviews revealed that staff were aware of the missing ring and discussed it in morning meetings, but there was confusion regarding who was responsible for reporting and investigating the incident. The Director of Nursing assumed the Social Service Director had reported and investigated the matter, while the Social Service Director did not consider the missing ring as abuse and did not log or report it. The CNA who initially received the report wrote a statement and submitted it as instructed, but was not contacted for further details. The family member of the resident did not receive any follow-up from the facility until weeks later, after the new Administrator became involved. The facility's own abuse policy requires all allegations of abuse, including misappropriation of property, to be reported immediately to the Administrator and in a timely manner to appropriate authorities such as IDPH. Despite this policy, the missing ring was not reported or investigated as required, and the incident was not documented in the facility's reportable or grievance logs. The lack of timely reporting and investigation resulted in a deficiency related to the facility's failure to follow its abuse prevention and reporting procedures.