Failure to Investigate Allegation of Misappropriated Cell Phone
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of misappropriation of a resident’s personal cell phone. The resident was admitted with depression and anxiety and had a Minimum Data Set (MDS) indicating moderate cognitive impairment, requiring substantial/maximal assistance for bed mobility and moderate assistance for transfers. On 02/13/2026, progress notes documented that the resident reported a family member had removed their personal phone and would not return it. The Social Service Assistant (SSA) documented a report to the state agency for possible exploitation or control of the resident’s communication device by family members. During an interview on 03/04/2026 at 9:17 AM, the SSA stated that after the resident’s allegation, they reported the concern to the state agency and left a voicemail for the family member but did not initiate or complete any investigation or attempt to locate the phone. The SSA confirmed no further action was taken beyond the report and voicemail. Later that morning, the resident stated that their family member had taken their cell phone and that they wanted it back, describing it as their only way to communicate with the outside world. The Administrator reported being unaware of the allegation and stated that staff should have initiated a grievance for a missing item and an investigation, and acknowledged that staff did not follow the facility’s policy for an allegation of misappropriation.
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