Failure to Maintain Accurate Inventory Records
Penalty
Summary
The facility failed to maintain a complete and accurate record of a resident's personal possessions upon admission and discharge. This deficiency was identified for one resident out of three sampled, specifically Resident 187. Upon review of the clinical records, it was found that the inventory list for Resident 187, who was admitted on October 23, 2024, and discharged on November 24, 2024, included sixteen personal items. However, the inventory list lacked the necessary signatures from the resident or their responsible party, as well as from a staff member, both at the time of admission and discharge. An interview with the Director of Nursing on January 16, 2025, confirmed the absence of these signatures, indicating a failure in the facility's process to ensure the protection of personal and property rights of residents, as required by the regulation.
Plan Of Correction
1. Resident 187 has discharged from the facility. 2. A facility wide audit of Inventory Sheets was conducted to ensure accuracy and appropriate signatures. 3. Licensed Nurses were re-educated on completing a Resident Inventory Sheet with signature on admission and discharge. The Administrative Assistant will complete random chart checks to ensure completion. 4. The NHA or designee will complete a resident inventory sheet audit weekly x 4 weeks and monthly x 2 months of resident admissions and discharges to ensure accuracy and appropriate signatures. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.