Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of a resident’s personal property to the State Agency as required by its abuse policy. One resident with Type 2 diabetes, non-pressure chronic skin ulcers, a history of malignant neoplasm of the bladder, and a BIMS score of 12 indicating moderately impaired cognition had a care plan identifying risk for falls and the need to keep personal items within reach. The resident’s conservator reported that the resident’s electronic tablet was missing after a hospital transfer and stated that the device had been stolen while the resident was in the hospital. The conservator reported notifying the Administrator, who allegedly stated the facility would investigate the missing device. Despite this notification, facility records from early 2025 through early 2026 showed no grievance filed regarding missing items or the missing tablet, and no State Reportable event was completed for the missing device. A social worker acknowledged being informed by the conservator that the tablet was missing and that a replacement was needed, but stated she was never told it was stolen and did not document this communication in the resident’s medical record. In interviews, the DNS, Administrator, and social worker confirmed that no investigation was completed and no report was made to the State Agency regarding the missing tablet, contrary to the facility’s abuse policy requiring alleged violations to be reported to the Administrator with notification to the State Agency and other parties.
