Failure to Investigate and Document Resident’s Report of Missing Jewelry
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal belongings when staff did not appropriately respond to the resident’s report of missing jewelry following a room change. The resident, who had multiple medical conditions including COPD, lung cancer, hemiplegia, dementia, and chronic respiratory failure, was under hospice services but had an intact cognitive status with a BIMS score of 14/15. After being moved to a different room, the resident reported that two gold rings, one with a purple stone and one with a green stone, were missing. The resident stated she reported the missing rings to the Administrator on the day of the room change. An anonymous complaint later alleged that several items were missing after the room change, including an antique amethyst birthstone ring that was described in detail and characterized as irreplaceable, and that the Administrator refused to replace it or reach an amicable solution. Despite these reports, there was no documentation of the concern in the grievance/complaint log or the missing items log for the relevant months, and the Administrator initially stated there were no grievances or concerns filed and that he was unaware of missing jewelry. The Ombudsman reported that a volunteer Ombudsman had informed the Unit Manager about the missing rings, and the Unit Manager believed the facility was already aware. The Administrator later confirmed he knew of the allegation a few days after the room change but did not complete a grievance/concern form or self-report the incident to the state agency because he felt the resident could not adequately describe the rings or when she last saw them and questioned whether the rings existed. The Social Worker reported searching the resident’s room and speaking with staff but had no documentation to show an investigation was completed, and neither the Administrator nor the Social Worker contacted the resident’s family to verify the presence of the rings. These actions and omissions occurred despite a facility policy defining misappropriation as wrongful use of a resident’s belongings or money without consent.
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