F0602

D

Failure to Protect Resident From Financial Misappropriation and Inadequate Documentation of Exploitation Incident

Tucson, Arizona Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident’s right to be free from financial misappropriation/exploitation of property by another resident and to ensure appropriate reporting of the incident. One resident, who was cognitively intact with a BIMS score of 13 and had diagnoses including anemia, COPD, weakness, and major depressive disorder, reported that money was being taken after befriending another, younger resident. This resident had a care plan addressing depression and psychosocial risks, including monitoring for changes in mood and behaviors related to situational stressors. Documentation shows that the resident became upset and distressed after an encounter involving being robbed by a fellow resident, later experiencing increased anxiety, sadness, and a desire to move to another facility.

The alleged perpetrator was also cognitively intact, with a BIMS score of 15, and had diagnoses including major depressive disorder, obesity, and life management difficulty, as well as a care plan for self-harmful ideation and poor impulse control. According to the facility’s incident follow-up report, the perpetrator stated that the victim initially gave permission to use her funds and then continued to use them without permission. Staff interviews revealed that the victim had given her debit card and cash to the other resident to hold, and that the other resident used the funds to buy clothes for herself and the victim, and to purchase coins for virtual slot games. Another staff member reported noticing boxes of purchases in the alleged perpetrator’s room and learning that the victim’s debit card was being used without permission.

The deficiency is further supported by inconsistencies and gaps in the facility’s documentation and reporting of the event. The incident follow-up report did not include the names of the residents involved. During the onsite survey, when a self-report for the relevant month involving the victim was requested, the administrator provided documentation that did not include any self-report for that period. The business office manager stated she had no documentation of the incident other than an investigator’s card, and the administrator reported having no prior knowledge of the incident and being unable to locate the reportable event or investigation in the facility’s records. Although staff described the situation as abuse and financial exploitation and referenced notifications to external agencies, the lack of a self-report in the requested timeframe and incomplete internal documentation demonstrate the facility’s failure to properly document and maintain records of the misappropriation incident, contributing to the cited deficiency.

The facility’s own Abuse and Neglect policy states that residents are to receive care in an environment free from misappropriation of property and exploitation, and that suspected abuse will be investigated based on facts, observations, and statements from the alleged victim and witnesses. In this case, the victim’s report of stolen money, the perpetrator’s admission of continued use of funds without permission, and staff observations of unusual purchases and changes in the victim’s demeanor all point to financial misappropriation by one resident against another. The absence of a complete, identifiable self-report and investigation record available for review, along with the omission of resident names in the incident follow-up report, shows that the facility did not fully adhere to its own policy requirements in documenting and tracking this substantiated misappropriation event.