Failure to Investigate and Document Missing Resident Property
Penalty
Summary
The facility failed to follow its policies and procedures for investigating missing items, specifically in the case of a resident with severe cognitive deficits and hearing loss. The resident was admitted with a history of cognitive communication deficit and right ear hearing loss, and her minimum data set assessment indicated severe cognitive impairment. After returning from a hospital stay, her inventory list included a gray bag, keys, charger for hearing aids, identification card, and two hearing aids. The gray bag, containing her hearing aids and other personal items, was reported missing, and the resident was unable to use her hearing aids since the bag went missing. Staff interviews revealed that the Social Services Director (SSD) was informed of the missing bag when nursing staff could not locate the resident's hearing aids. The SSD learned from the resident that a personal caregiver, not employed by the facility, may have had the bag, but the SSD did not follow up with the caregiver due to lack of contact information and only knowing the caregiver's first name. The SSD did not document or investigate the missing items in accordance with facility policy, which requires loss or theft of resident property worth $25 or more to be documented, reported, and investigated, with completed reports filed in the Social Service Department Office. Further interviews with facility staff, including the Quality Assurance (QA) Nurse and Director of Nursing (DON), confirmed that the expected procedure was not followed. The SSD did not attempt to verify with the personal caregiver whether the bag was given to her or was still missing, despite the resident's cognitive impairments. There was no recorded investigation in the facility's missing items binder regarding the missing gray bag or hearing aids, and the lack of follow-up and documentation failed to protect the resident's personal property as required by facility policy.