Failure to Investigate Allegation of Misappropriated Resident Property
Penalty
Summary
Facility staff failed to follow their 2017 Investigation policy requiring that every allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriated resident property be thoroughly investigated and reported to the administrator and State Survey Agency within five days. The policy specified that residents, employees, family members, visitors, and others may be interviewed about their knowledge of events, and emphasized that all health care workers are mandatory reporters of abuse. Despite this, when a cognitively intact resident reported a missing tablet, staff only documented the concern in the grievance log and noted they were still searching for the item, without initiating or documenting a formal investigation as required by policy. The resident’s quarterly MDS showed the resident was cognitively intact and had been admitted earlier in the year. The grievance log entry indicated the resident reported the tablet missing, but the medical record for the relevant month contained no documentation of an investigation into the missing property. In an interview, the resident stated the tablet had been missing for about a month, that it had been reported to an unknown staff member, and that there had been no response to the grievance. In a separate interview, the administrator acknowledged awareness of the missing tablet and stated that staff searched for the item and that he/she spoke with staff, but admitted not conducting a full investigation, not following the misappropriation of property policy, and not interviewing other residents, believing instead that the item would likely turn up as missing items typically do.
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