Failure to Maintain Documentation of Thorough Investigation of Alleged Financial Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation that an alleged incident of financial misappropriation between two residents was thoroughly investigated. One resident with major depressive disorder, obesity, and a history of self-harm ideation was cognitively intact per a BIMS score of 15 and did not exhibit behavioral symptoms. Another cognitively intact resident with anemia, COPD, weakness, and major depressive disorder, with a BIMS score of 13, reported being financially exploited by this fellow resident. Clinical notes show that the alleged victim became upset and anxious after reporting being robbed by another resident, spoke with detectives, experienced transient chest pain, and expressed a desire to move to another facility, eventually refusing to return after a hospital stay. The facility’s incident follow-up report for the alleged financial misappropriation did not identify the residents involved by name or number and lacked interview statements from staff or other residents who might have interacted with the two residents. Although the report stated that the interdisciplinary team completed a thorough investigation, including outreach to police, APS, and the ombudsman, it did not contain the underlying interview documentation or detailed investigative findings. During the survey, when a self-report for the month of the incident involving the alleged victim was requested, the administrator produced no self-report related to that resident for that period. Interviews with the BOM, SSD, LPN, and administrator confirmed that an allegation of financial exploitation had occurred between two residents, that it was considered abuse or financial exploitation by staff, and that external agencies and law enforcement were contacted. However, the BOM stated she had no documentation of the incident other than an investigator’s card and indicated that the SSD might have documentation. The SSD reported notifying APS and other parties and described steps she took after learning of the situation, but no corresponding investigative documentation was produced for surveyor review. The administrator, who was not employed at the time of the incident, reported having no knowledge of the event until the day before the interview and was unable to locate the reportable event or the investigation in the facility’s records, acknowledging that such a report and investigation should be retained and available. This lack of accessible, complete investigative documentation for the alleged misappropriation constitutes the cited deficiency.
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