Failure to Timely Report Alleged Abuse and Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse and misappropriation of property involving a cognitively impaired resident was reported immediately, and no later than 24 hours, to the administrator as required by facility policy. The resident was an adult male with diagnoses including vitamin deficiency, pain, hypertensive heart disease, type 2 diabetes, and muscle weakness, and had a BIMS score of 12/15 indicating moderate cognitive impairment. His care plan identified risk for impaired cognitive function related to psychotropic drug use, history of stroke, and mild cognitive impairment, with interventions focused on clear communication, reorientation, and supervision as needed. According to interviews and record review, during a night shift, an LVN took the resident’s personal cell phone without his consent while a CNA held the resident’s arms down and did not assist him out of bed. The resident reported that two staff members were involved, with one holding his hand while the other removed his phone, and that his phone was not returned for the remainder of the night, leaving him unable to call anyone until the following day. The resident stated that no staff communicated with him about the phone’s whereabouts and that no action was taken regarding the incident until the next day, when he personally reported the situation to the administrator. The administrator, DON, LVN, and CNA all confirmed in interviews that the incident was not reported to facility leadership at the time it occurred, despite facility policy requiring immediate reporting of all alleged violations to the administrator and other authorities within specified timeframes. The administrator stated that staff are trained monthly on abuse, neglect, and exploitation and are required to report incidents immediately, but in this case the LVN did not notify the administrator, stating she did not initially think of it and did not consider the resident to be abused. The CNA also did not report the incident and indicated she believed the nurse in charge was responsible for reporting. This failure to report resulted in the administrator and DON only learning of the allegation the following day when the resident reported that his phone had been taken and not returned.
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.