Failure to Investigate Missing Resident Property
Penalty
Summary
The facility failed to thoroughly investigate missing personal items for a resident with severe cognitive impairment, including two phones, an abdominal binder, and dentures. The resident's daughter reported the missing phone and abdominal binder to staff, and the missing items were noted in the facility's log. However, there was no evidence that these incidents were reported to or investigated by administration, nor was there documentation of any formal investigation or self-reported incident (SRI) being completed. Staff interviews revealed uncertainty about the whereabouts of the items and whether they had been reported missing, despite the facility's policy requiring immediate reporting and investigation of such incidents. The resident in question had diagnoses of heart disease, dementia, anxiety, and depression, and required significant assistance with daily activities. The care plan indicated the dentures had been missing for several months, but there was no documentation of an investigation or administrative follow-up. Observations confirmed the missing items were not present in the resident's room or designated storage areas. The administrator acknowledged that no investigation had been initiated for the missing items, contrary to facility policy, which mandates investigation and documentation of alleged misappropriation of resident property.