F0607

D

Failure to Implement Abuse and Misappropriation Investigation Policy and Maintain Required Records

Mesa, Arizona Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse, neglect, and misappropriation policy by not conducting or maintaining thorough investigations and related clinical documentation for multiple allegations of abuse, neglect, and theft involving 11 residents. State Agency (SA) records showed that various incidents, including misappropriation of property, resident‑to‑resident altercations, and alleged sexual contact, had been reported and that the facility had indicated investigations were conducted. However, during the survey, the facility was unable to produce investigation reports, five‑day reports, or contemporaneous clinical documentation such as nursing progress notes, care plans, and Minimum Data Set (MDS) assessments for the timeframes of the allegations, despite policy requirements to identify, document, and investigate abuse, neglect, exploitation, and misappropriation.

For one resident who reported loss of personal property allegedly involving a nurse aide, SA records indicated the facility conducted an internal investigation immediately after the incident, but the facility could not provide the investigation report and denied that the resident had ever resided there, even though SA MDS data showed an admission. Another resident with dementia, bipolar disorder, anxiety, depression, and mobility issues had an allegation of misappropriation by a payee; yet the EHR contained no care plan, nursing notes, or task records for the relevant month, and the facility stated it did not possess any supporting documentation. In a documented resident‑to‑resident altercation where one resident struck another’s hand in the dining room, the facility reported that staff separated the residents and conducted an investigation, but later could not produce a five‑day report, a face sheet for one of the residents, or nursing documentation for the time of the incident.

Additional SA‑reported resident‑to‑resident altercations and misappropriation allegations similarly lacked corresponding facility records. In one case, a resident with traumatic brain injury, anxiety, and depression was reportedly struck on the shoulder by another resident with schizoaffective disorder, traumatic brain injury, and multiple psychiatric diagnoses, but there were no nursing progress notes for either resident for the period of the incident and no five‑day investigation report. Another resident with hypertension, prior transient ischemic attack, and adjustment disorder had an alleged misappropriation of financial resources, yet there was no care plan for the year of the allegation, no progress notes for that period, and no investigation report. A resident with traumatic brain injury, legal blindness, seizures, and serious mental illness reported being attacked by another resident, but the facility lacked MDS, care plans, and progress notes for the months surrounding the allegation.

Further, an allegation of inappropriate sexual contact between roommates was reported, but the facility’s EHR contained no record for the alleged perpetrator, and for the alleged victim there was no MDS or care plan on or before the date of the incident and no nursing notes until much later. Another resident who discovered that insurance catalog benefits had been nearly depleted was not found in the EHR at all, and the facility stated it did not have records for residents or incidents prior to a change of ownership. The Administrator reported that the facility did not have access to medical records, five‑day investigation reports, or self‑reported incidents from before the ownership change, and the Medical Records Supervisor stated that such records should be retained for ten years but that no paper records existed for residents prior to that date. These inactions and missing records demonstrate that the facility did not follow its abuse prevention policy requiring immediate reporting, protection of alleged victims, and thorough identification and documentation of abuse, neglect, exploitation, and misappropriation.

The facility’s written policy on abuse prevention and prohibition stated that each resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that staff with knowledge of actual or potential violations must report them immediately to the Administrator. The policy further required the facility to identify and document abuse, neglect, exploitation, and misappropriation, including through assessments and review of occurrences, patterns, and trends such as resident‑to‑resident altercations, and to respond immediately to protect alleged victims and preserve the integrity of investigations, including examination of alleged victims for signs of injury via physical and/or psychosocial assessment. The absence of investigation reports, contemporaneous clinical documentation, and retained records for the cited residents and incidents shows that these policy requirements were not implemented for the 11 sampled residents associated with the SA‑reported allegations.