Failure to Inventory and Protect Resident's Durable Medical Equipment
Penalty
Summary
Facility staff failed to protect a resident's property from loss by not properly inventorying a right hand resting splint (RHRS) on the resident's clothing and possession form when it was received. The RHRS, a piece of durable medical equipment prescribed to assist with the resident's contracture management, was not documented as received on the inventory form, and there was no record of its loss in the resident's progress notes. Despite physician orders for the resident to use the RHRS at night, staff did not update the inventory or document the device's whereabouts after it was last seen. The resident, who had moderately impaired cognition and was dependent on staff for most activities of daily living, reported that staff lost the RHRS shortly after it was received and did not respond to requests for its return or provide information about its location. Interviews with staff confirmed that the RHRS was last seen the day after it was received, and that staff were responsible for tracking and documenting the device in the resident's records. However, there was no evidence that staff reported the device missing or investigated its disappearance as required by facility policy. The facility's policy on personal property required that resident belongings be inventoried upon admission and updated as necessary, and that any complaints of missing property be promptly investigated. In this case, the lack of documentation and follow-up regarding the RHRS resulted in the resident being without the prescribed device, with no indication in the records that staff took steps to locate or account for the missing equipment.
Plan Of Correction
F584 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 2 was referred to the facility's rehabilitation department for a reassessment of their need for durable medical equipment (DME). If deemed necessary, an appointment with an external rehabilitation provider will be coordinated per resident preference. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 18, 2025, the Director of Nursing (DON) or designee conducted a review of all residents with splints in the facility to ensure that the durable medical equipment (DME) was accurately accounted for and easily locatable. No additional findings were noted. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 17 to March 21, the Director of Nursing (DON) or designee conducted an in-service training for licensed nursing staff on the importance of accurately inventorying resident durable medical equipment (DME) and ensuring its proper placement. This training aims to meet resident needs effectively and eliminate barriers to care. Additionally, the Medical Records department or designee will audit admissions and readmissions to verify proper inventory logging of applicable DME. Any negative findings will be reported to the DON for further review. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 21st, 2025 F 584