Failure to Report and Document Alleged Theft and Intrusion per Abuse/Misappropriation Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies for reporting and investigating theft and misappropriation of resident property, including timely reporting to the state licensing/certification agency and completion of a follow-up investigation report. A resident admitted with DM, malignant neoplasm of the endocrine pancreas, muscle weakness, difficulty walking, and moderate to severe depressive symptoms had intact cognitive skills but no documented personal inventory list in the medical record. The Medical Records Director confirmed that the resident’s personal belongings were not inventoried or documented. On the morning in question, the resident’s family member reported that an unhoused individual entered the facility without staff knowledge, stayed and slept in an unassigned bed in the resident’s room, and behaved strangely. The family member stated the resident pressed the call light multiple times without staff response and later felt terrified and unsafe. The family member also reported that the resident’s mobile phone was discovered missing that morning and reported this to facility staff. An LVN stated she saw the unknown individual in the resident’s room early that morning, noted he appeared homeless, was carrying a plastic bag, and claimed he had “checked in” while holding a mobile phone. The LVN escorted him out but did not document the incident, did not report it to management, and did not assess or check on the resident afterward. The DON and Administrator later acknowledged that an unknown person had gained access through a malfunctioning front door, that the resident’s phone went missing and was later retrieved broken, and that the incident was investigated internally and reported to police. However, they stated it was not reported to the state licensing/certification agency, and there was no documentation of the incident or resident assessment in the medical record, contrary to facility policies requiring reporting all such allegations to local, state, and federal agencies as required, and documenting and reporting investigation findings, including a follow-up report within five business days.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.